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SURGICAL  PATHOLOGY. 


LECTURES 


SURGICAL    PATHOLOGY, 


DELIVEEED    AT    THE 


ROYAL  COLLEGE  OF  SURGEONS  OF  ENGLAND. 


BY 


JAMES    PAGET,   F.R.S., 

SURGEON   EXTEAORDINAEY   TO   HER   MAJESTY   THE   QUEEN  ;    SURGEON  IN   ORDINARY   TO    HIS   ROYAL   HIGHNESS   THE 
PRINCE   OF   WALES  ;   SURGEON  TO   ST.   BARTHOLOMEW'S    AND   CHRIST'S   HOSPITALS. 


REVISED    AND    EDITED    BY 

WILLIAM   TUENEE,  M.B.  Lond.,  F.E.C.S.E.,  F.E.S.E., 

SENIOR  DEMONSTRATOR  OF  ANATOMY  IN  THE  UNIVERSITY  OF  EDINBURGH. 


i^Mrd  g^ma't^au  Edition. 


PHILADELPHIA: 
LINDSAY    &    BLAKISTON. 

1865. 


?1P 


-ec  Co  /) 


CAXTON  PRESS  OF  SHERMAN  &  CO. 


TO 


P.  M.  LATHAM,  M.D.,  and  GEORGE  BURROWS,  M.D., 


WHOSE    SKILL    HAS    BEEN    PERMITTED    TO    PRESERVE    MY    LIFE, 


WHOSE  FRIENDSHIP  ADDS  LARGELY  TO  MY  HAPPINESS, 


AND    TO    WHOSE    TEACHING 


I    SHALL    ATTRIBUTE    MUCH    OF    WHATEVER    GOOD    MY    WORK    MAY    DO, 


i  iXuXmU  tW  f  0twnu, 


WITH    GRATITUDE.    AFFECTION,    AND    RESPECT. 


PEEFACE 


THIS     EDITION. 


When  the  time  came  for  preparing  a  Second  Edition  of  these  Lec- 
tures, I  was  anxious  that  they  should  be  revised  with  all  the  light  of  the 
knowledge  of  Pathology  acquired  since  their  publication.  But,  although 
I  had  collected  some  materials  for  this  purpose,  yet  a  thorough  revision 
of  the  whole  subject  was  a  task  for  which  I  felt  unfit.  For  in  the  pas- 
sage of  nine  years,  I  had  been  carried  into  the  active  practice  of  my 
profession ;  and,  at  their  end,  had  no  sufficient  time  for  either  studying 
or  thinking  carefully  about  the  many  facts  and  probabilities,  and 
guesses  at  truth  which  had  been  added  to  Pathology.  I  was,  therefore, 
glad  to  be  able  to  commit  the  work  of  revision  to  my  friend  and  former 
pupil,  Mr.  Turner,  whom  I  know  to  be  not  only  very  conversant  with 
the  progress  of  medical  science,  but  able  to  test  others'  observations  by 
his  own.  It  is  not  for  me  to  say  how  well  he  has  done  the  work,  for  I 
have  so  worked  with  him  as  to  be  equally  with  him  responsible. 

James  Paget. 


PREFACE 


SECOND   VOLUME    OF    THE   FIRST  EDITION. 


The  Lectures  in  this  volume,  and  especially  those  on  Cancers,  are 
enlarged  far  beyond  their  original  extent,  by  the  addition  of  cases, 
statistical  tables,  and  various  statements  which  may  be  worth  reading, 
but  of  which  the  recital  could  not  be  made  agreeable  to  an  audience. 
In  making  these  additions,  I  have  endeavored  to  adduce  sufficient  evi- 
dence for  the  general  conclusions  I  have  drawn,  without  encumbering 
the  book  with  such  a  mass  of  details  as  would  be  repulsive  to  the  ma- 
jority of  readers.  I  can  hardly  imagine,  that  a  full  relation  of  so  many 
cases  as  I  have  referred  to  would  be  acceptable  to  any  besides  those 
who  are  engaged  in  the  especial  study  of  the  subjects  of  the  Lectures. 
To  all  who  are  so  occupied,  I  will  very  gladly  give  whatever  further 
information  my  manuscript  records  of  cases  can  supply. 

It  is  an  unavoidable  defect  of  lectures  on  general  pathology,  that 
they  cannot  be  conveniently  used  in  the  study  of  the  diseases  of  par- 
ticular organs.  I  have  endeavored  to  amend  this,  in  some  measure,  by 
a  full  index,  referring,  under  the  title  of  each  organ,  to  the  descrip- 
tions of  the^tumors  of  which  it  is  most  apt  to  be  the  seat. 


PREFACE 


THE    FIRST    EDITIOI^. 


Nearly  all  the  Lectures  in  these  volumes  were  delivered  at  the 
Royal  College  of  Surgeons,  during  the  six  years,  from  1847  to  1852, 
in  which  I  held  the  office  of  Professor  of  Anatomy  and  Surgery  to  the 
College.  So  many  listened  favorably  to  them,  that  I  venture  to  hope 
I  am  not  wrong  in  thus  enabling  many  more  to  read  them.  But,  in 
offering  them  to  this  larger  class,  some  explanation  of  their  scope  and 
plan  seems  necessary. 

The  circumstances  of  my  election  to  the  Professorship  indicated  the 
Pathological  Museum  of  the  College  as  the  appropriate  subject  of  the 
Lectures  ;  and  the  first  portion  of  the  Museum,  devoted  to  the  illustra- 
tion of  General  Pathology,  seemed  to  offer  the  best  plan  by  which  the 
knowledge  acquired  in  a  long  study  of  the  whole  collection  might  be 
communicated. 

The  modes  were  many  in  which  such  a  subject  might  be  treated  in 
lectures ;  but,  as  circumstances  had  decided  the  subject,  it  seemed  well 
to  let  them  determine,  also,  the  method,  and  to  adopt  that  which  was 
most  natural  to  one  engaged  in  the  simultaneous  practice  of  surgery 
and  teaching  of  physiology.  Thus  guided,  I  designed  to  give  lectures 
which  might  illustrate  the  general  pathology  of  the  principal  surgical 
diseases,  in  conformity  with  the  larger  and  more  exact  doctrines  of 


Xll  PREFACE    TO    THE    FIRST    EDITION. 

physiology ;  and  tlie  plan  seemed  tlie  more  reasonable,  because  it  was 
in  accordance  Tvith  the  constant  design  of  the  great  founder  of  the 
Museum. 

The  Museum  limited,  while  it  indicated,  the  subjects  of  the  Lectures. 
They  were,  therefore,  not  constructed  to  form  a  system  of  surgical  pa- 
thology :  several  subjects,  which  might  fill  considerable  places  in  such 
a  system,  were  scarcely  alluded  to  in  them ;  and,  although  I  have  added 
some  Lectures,  which  could  not  be  conveniently  included  in  any  of  the 
courses,  yet  I  have  not  gone  beyond  the  range  of  such  pathology  as  a 
Museum  may  illustrate. 

The  wood-engravings  are,  for  the  most  part,  copied  from  the  same 
specimens  and  drawings  as  were  the  diagrams  used  in  the  Lectures ; 
and  I  wish  them  to  be  regarded  as  intended  for  only  the  same  purpose 
as  such  diagrams  may  serve  ;  viz.,  that  of  assisting  the  more  difiicult 
parts  of  the  descriptions  of  the  objects  to  which  they  refer. 

I  have  endeavored  to  make  the  Lectures  less  incomplete,  and  more 
correct,  by  the  aid  of  numerous  facts  ascertained  since  they  were  de- 
livered, and  have  added  to  them  many  things  which  time,  or  their  in- 
aptness  for  oral  delivery,  obliged  me  to  omit.  Among  these  are  the 
references  to  specimens  and  illustrations ;  as  well  as  to  numerous  au- 
thors who  could  not,  in  speaking,  be  conveniently  quoted,  but  whom  I 
am  now  glad  to  acknowledge  as  instructors.  And  I  will  here  offer  my 
thanks  to  some,  to  whom  my  debts  are  more  than  would  be  expressed, 
even  by  referring  to  all  the  occasions  on  which  their  works  have  aided 
me  in  the  composition  of  the  Lectures.  Such  acknowledgments  are 
due,  especially,  to  Mr.  Lawrence,  Mr.  Stanley,  Professor  Owen,  and  Dr. 
Carpenter,  from  whom,  during  many  years  of  valued  friendship,  I  have 
derived,  at  every  interview,  either  knowledge,  or  guidance  in  observing 
and  in  thinking.  I  am  deeply  obliged,  also,  to  all  my  colleagues  on  the 
staff  of  St.  Bartholomew's,  from  whom  the  constant  help  that  I  receive 
adds  daily  to  the  debt  of  gratitude  incurred  during  my  pupilage.  And 
there  are  many  friends,  besides,  to  whom  it  is  my  happiness  to  be  in- 
debted for  knowledge  used  in  these  Lectures,  and  whom  I  thank  col- 


PREFACE    TO    THE    FIRST    EDITION.  Xlli 

lectively,  not  because  I  owe  them  little,  but  because  I  cannot  name 
them  all,  and  cannot  thank  some  without  appearing  ungrateful  to  the 
rest. 

I  desire,  in  conclusion,  to  express  my  acknowledgments  to  the  Mem- 
bers of  the  Council  of  the  College,  both  for  the  repeated  honor  they 
conferred  on  me  by  so  often  electing  me  to  the  Professorship,  and  for 
the  kindness  with  which  many  of  them  devoted  their  valuable  time  to 
attendance  at  the  Lectures.  The  encouragement  they  thus  afforded  me 
makes  me  hope,  that  the  labor  with  which  I  strive  to  justify  their  choice, 
may  have  some  success  in  the  promotion  of  scientific  surgery. 


TITLES  OF  THE  LECTURES. 


1.  Nutrition — its  Nature,  Purpose,  and  Conditions, 

2.  The  Conditions  Necessary  to  Healthy  Nutrition 

3.  The  Formative  Process — Growth,  . 

4.  Hypertrophy, 

5.  Atrophy — Degeneration, 

6.  Atrophy^  , 

7.  General  Considerations  on  the  Repair  and 

OF  Injured  and  Lost  Parts, 

8.  The  Materials  for  the  Repair  op  Injuries, 

9.  The  Processes  of  Repair  of  Wounds, 

10.  The  Processes  of  Repair  of  Wounds, 

11.  The  Repair  of  Fractures, 

12.  Healing  of  Injuries  in  Various  Tissues, 

13.  Phenomena  op  Inflammation,  . 

14.  Products  of  Inflammation, 

15.  Developments  of  Lymph,  .... 

16.  Degeneration  op  Lymph,  .... 

17.  Changes  produced  by  Inflammation  in  the 

Affected  Part, 

18.  Nature  and  Causes  of  Inflammation,     . 

19.  Mortification,  .  ^ 

20.  Specific  Diseases, 

21.  Classification  of  Tumors, 

22.  Simple  or  Barren  Cysts,  .... 

23.  Compound  or  Proliferous  Cysts, 

24.  Fatty  and  Fibro-cellular  Tumors  :  Painful 

Tumors, 

25.  Fibrous  Tumors,        ..... 

26.  Cartilaginous  Tumors,     .         .         ;        . 

27.  Part  1.  Myeloid  Tumors, 
Part  2.  Osseous  Tumors,  .... 


Reproduction 


Tissues  of  the 


Subcutaneous 


PAGE 

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38 
59 
70 
81 
96 

119 
132 
145 
158 
175 
189 
208 
227 
245 
258 

276 
293 
309 
321 
337 
353 
373 

396 
422 
435 
461 
472 


XVI  TITLES    OFTHB    LECTURES. 

LECTURE  PAGE 

28.  Part  1.  Glandular  Tumors, 484 

Part  2.  Vascular  or  Erectile  Tumors, 495 

29.  Recurrent  Tumors,' 508 

30.  Scirrhous  or  Hard  Cancer  :  Part  1.  Anatomy,      .         .         .  519 

"              "              "           Part  2.  Pathology,  .         .         .  541 

31.  Medullary  Cancer  :  Part  1.  Anatomy, 561 

"                ''          Part  2.  Pathology,        ....  581 

32.  Epithelial  Cancer  :  Part  1.  Anatomy, 596 

"                "         Part  2.  Pathology,         ....  624 

33.  Melanoid,  H^matoid,  Osteoid,  Villous,  Colloid,  and  Fibrous 

Cancers, 638 

34.  General  Pathology  of  Cancer  :  Part  1.  Conditions  preced- 

ing the  Cancerous  Growth, 668 

35.  The  same  :  Part  2.  Structure  and  Life  of  the  Cancerous 

Growth, 687 

36.  Tubercle, 707 


LIST  OE  ILLUSTEATIONS. 


1.  Development,  Growth,  and  Separation  of  an  Eyelash, 

2.  Symmetrical  Disease  of  a  Lion's  Pelvis, 

3.  Hydrocephalic  Skull,  ...... 

4.  Skull  Thickened,  especially  at  the  Centres  of  Ossification, 

5.  Tibia,  elongated  and  curved,       ..... 

6.  Fatty  Degeneration  of  Fibres  of  the  Heart :  from  Dr.  Quain, 
7-8-9.  Fatty  Degeneration  of  minute  Cerebral  Vessels, 

10.  Repair  of  Crystals,     ....... 

11.  Repair  of  Hydra  Tuba:  from  Sir  J.  G.  Dalyell, 

12.  Repair  of  Tub ularia :  from  the  same, 

13.  Vessels  and  Minute  Structure  of  an  Organized  Blood-clot, 

14.  Granulation-cells, 

15.  Nucleated  Blastema, 

16.  Outgrowth  of  new  Bloodvessels, 

17.  Channelling  of  new  Bloodvessels, 

18.  Bloodvessels  of  Granulations, 

19.  A  Vascular  Loop  among  Granulation-cells, 

20.  Pus-cells, 

21.  Repair  of  Fracture  with  Ensheathing  Callus, 
22-23-24.  Repairs  of  Fractures  with  Intermediate  Callus, 
25.  Repair  of  divided  Tendons,         ..... 
26-27.  Repair  of  Skin, 

28.  Vessels  of  a  Rabbit's  Ear  ;  enlarged  in  Inflammation  :  from  Hunter, 

29.  Small  Bloodvessels  dilated  in  Inflammation, 
30-31.  Vessels  of  the  Bat's  Wing;  enlarged  in  Inflammation, 

32.  Corpuscles  of  Inflammatory  Blood :  from  Wharton  Jones, 

33.  Pigmental  Degeneration  in  Mucus-cells, 

34.  Bloodvessels  of  Adhesions,  .         ... 

35.  Lymphatics  of  Adhesions  :  from  Schroeder  van  der  Kolk, 

36.  Withered  Lymph-corpuscles,        ..... 

37.  Fatty-degenerate  Lymph-corpuscles,    . 

38.  Bloodvessels  of  an  Abscess-wall,         .... 

39.  Humerus  swollen  in  Inflammation,      .... 

40.  Separation  of  the  Laminae  of  the  Wall  of  a  Femur,    . 

41.  Abscess  in  a  Tibia,     ....... 

42.  Atrophy  of  the  Head  and  Neck  of  a  Femur, 

43.  Diagram  of  an  Abscess, '    . 

B 


PAGE 

30 

35 

74 

75 

77 

105 

115 

122 

126 

127 

135 

141 

143 

160 

162 

162 

163 

169 

181 

183,  186 

192 

206 

210 

212 

217 

223 

244 

256 

257 

262 

263 

269 

277 

278 

280 

280 

282 


XVlll 


LIST    OF    ILLUSTRATIONS. 


44.  Development  of  Cysts  in  the  Kidney:  from  Rokitansky, 

45.  Ovary,  with  many  Cysts,      ...... 

46.  Proliferous  Ovarian  Cyst,    ...... 

47.  Minutely  Proliferous  Ovarian  Cyst,     .... 

48.  Cystic  disease  of  the  Chorion;     ..... 

49.  Mammary  Cyst,  with  Endogenous  Growth, 

50.  A  similar  Cyst,  with  Pedunculated  Growths, 

51.  Similar  Cysts,  clustered  and  filled,       .... 

52.  Microscopic  Structures  of  a  Fibro-cellular  Tumor, 

53.  Section  of  a  Fibro-cellular  Tumor,       .... 

54.  Diagram  sections  of  a  Uterine  Outgrowth  and  a  Uterine  T 

55.  Minute  Structure  of  a  Uterine  Fibrous  Tumor, 

56.  Calcareous  Deposit  in  a  Fibrous  Tumor :  from  Dusseau, 

57.  Section  of  a  Fibrous  Tumor  from  ihe  Hip, 

58.  Sections  of  Fibrous  Tumors  on  and  within  the  Lower  Jaw 
59-62.  Microscopic  Structures  of  Cartilaginous  Tumors,    . 

63-63A.  The  same, 

64-65.  The  same,     ........ 

66.  Cartilaginous  and  Medullary  Tumor,   .... 

67.  Microscopic  Structures  of  a  soft  Cartilaginous  Tumor, 

68.  Cartilaginous  Tumor  of  the  Humerus, 

69.  Cartilaginous  Tumors  of  the  Hand,    .... 

70.  Minute  Structures  of  mixed  Cartilaginous  Tumors, 

71.  Minute  Structures  of  Myeloid  Tumors, 

72.  Myeloid  Tumor  of  the  Skull, 

73.  Minute  Structures  of  the  same,  ..... 

74.  Osseous  Tumor  of  the  Face  and  Skull, 

75.  Minute  Structures  of  Mammary  Glandular  Tumors,    . 

76.  The  Same  of  Labial  Tumors,      ..... 

77.  Erectile  Tumor, 

78.  Bloodvessels  of  an  Erectile  Tumor,     .... 

79.  Microscopic  Structures  of  a  Recurring  Fibroid  Tumor, 

80.  The  same ;  from  another  specimen,     .... 

81.  Microscopic  Structure  of  a  Fibro-nucleated  Tumor, 
82-83.  Scirrhous  Cancers  of  the  Mammary  Gland,    . 

84.  Scirrhous  Cancer-cells  among  the  Tissues  of  the  Skin, 

85.  Cancer-cells  and  Free  Nuclei, 

86.  Withered  Cancer-structures, 

87.  Degenerate  Cancer-structures,     . 

88.  Scirrhous  Cancer  in  a  Humerus, 

89.  Scirrhous  Cancer  of  the  Rectum, 
90-95.  Minute  Structures  of  Medullary  Cancers, 
96-97.  Development  of  Cancer-stroma :  from  Rokitansky, 

98.  Epithelial  Soot-cancer  of  the  Hand,  .... 

99.  Narrow-based  Epithelial  Cancer,         .        .         .         . 
100.  Deep-seated  Epithelial  Cancer  of  the  Tongue,     . 
101-4.  Minute  Structures  of  Epithelial  Cancer, 


LIST    OF    ILLUSTRATIONS. 


XIX 


105.  Diagram  of  the  Formation  of  Laminated  Capsules:  from  Rokitansky,         .  614 

106.  Melanoid  Cancer, 639 

107.  Minute  Structures  of  the  same, 640 

108.  Osteoid  Cancer  of  the  Femur, 648 

109.  Osteoid  Cancer  of  a  Lymphatic  Gland,        .         , 648 

110.  Fibrous  Tissue  of  an  Osteoid  Cancer, 649 

111.  Dendritic  Vegetation  :  from  Rokitansky,     .......  656 

112.  Fibrous  Tissue  of  a  Colloid  Cancer, 660 

113.  Minute  Structures  of  Colloid  Cancer :  from  Lebert  and  Rokitansky,    .         .  661 

114.  Tissue  of  a  Malignant  Fibrous  Tumor  (Fibrous  Cancer),     ....  667 

115.  Proliferation  of  the  Nuclei  within  Muscular  Fibres,  in  Cancer  of  the  Muscles,  689 
116-117.  Minute   Structure  of  Pulmonary  Tubercle:   from  Schroeder  van  der 

Kolk, 709-710 


LECTURES 


SURGICAL   PATHOLOGY. 


LECTURE   L 

NUTRITION — ITS    NATURE,  PURPOSE,  AND    CONDITIONS. 

Mr.  President  and  Gentlemen  :  I  believe  that  I  owe  the  honor  of 
being  elected  Professor  of  Anatomy  and  Surgery  to  the  College,  chiefly, 
to  my  having  been  long  engaged  in  the  study  of  the  pathological 
department  of  the  Museum,  while  arranging  and  describing  it,  under 
the  superintendence  of  Mr.  Stanley,  for  the  new  Catalogue.  I  may, 
therefore,  fairly  suppose  it  to  be  the  wish  of  the  Council  that,  as  the 
Museum  is  open  to  the  examination  of  the  members  and  pupils  of  the 
College,  and  of  men  of  scientific  pursuit,  so  should  be  the  knowledge 
and  the  opinions  which  it  has  supplied  or  suggested  to  those  who  have 
had  occasion  to  study  it  most  deeply.  For,  indeed,  to  what  thus  grows 
out  of  the  study  of  the  Museum,  the  College  has,  in  some  measure,  the 
right  which  the  proprietor  has  to  the  produce  of  the  cultivated  soil. 
And  when,  through  a  long  time  past,  your  most  learned  Hunterian 
Professor  Owen  has  every  year  brought  in,  from  every  source,  so  large 
a  store  of  deep  and  wide-extending  knowledge,  of  sagacious  interpreta- 
tion, and  acute  suggestion  of  the  ways  of  Nature,  I  scarcely  wonder 
that  some  return  should  be  looked  for  from  an  inferior  laborer  in  the 
field. 

The  subjects  on  which  I  shall  first  beg  your  favorable  hearing  are 
those  to  the  general  illustration  of  which  the  first  two  series  of  prepara- 
tions in  the  Pathological  Museum  are  devoted — namely,  hypertrophy 
and  atrophy ;  the  simple  excess,  and  the  simple  deficiency,  of  nutrition 
in  parts.  But  let  me  previously  speak  of  the  healthy  nutrition  of  the 
tissues,  and,  herein  especially,  of  the  formative  process  which  maintains 
them  by  assimilation. 

In  the  natural  course  of  healthy  life,  the  formative  process  manifests 
itself  in  three  modes,  which,  though  they  bear  difierent  names,  and  are 

3 


26  nutrition: 

sometimes  described  as  if  they  were  wholly  different  things,  yet,  proba- 
bly, are  only  three  expressions  of  one  law,  three  effects  of  the  same 
force  operating  in  different  conditions.  The  three,  enumerating  them 
in  the  order  of  their  time,  are  development,  growth,  and  assimilation  or 
maintenance.  To  these  succeeds  degeneration,  or  decay,  as  naturally, 
but  probably  through  a  deficiency  in  the  normal  formative  force. 

By  development  we  mean  generally  the  process  by  which  a  tissue  or 
organ  is  first  formed ;  or  by  which  one,  as  yet  imperfectly  formed,  is  so 
changed  in  shape  or  composition  as  to  be  fitted  for  a  higher  function, 
or,  finally,  is  advanced  to  the  state  in  which  it  exists  in  the  most  perfect 
condition  of  the  species. 

We  must  carefully  distinguish  development  from  mere  increase ;  it  is 
the  acquiring  not  of  greater  bulk,  but  of  new  forms  and  structures, 
which  are  adapted  to  higher  conditions  of  existence.  For  example, 
when  in  the  embryo  groups  of  primordial  nucleated  cells  are  converted 
into  the  tissues  characteristic  of  the  ultimate  structure  of  the  part  in 
which  the  conversion  is  effected,  there  is  not,  necessarily,  an  increase  in 
size ;  or  if  there  be,  there  is  something  more ;  there  is  a  change  of 
texture,  and  an  acquirement  of  power,  adapted  to  a  higher  state  of 
existence:  these  constitute  development.  So,  when  from  the  simple 
cavity  and  walls  of  the  embryonic  digestive  system,  the  stomach,  in- 
testines, liver,  pancreas,  and  other  organs  are  produced,  these  are 
developed ;  there  is  increase,  but,  at  the  same  time,  something  more 
than  mere  increase. 

The  distinction  between  development  and  increase,  or  growth,  is  well 
shown  in  this, — that,  sometimes,  even  in  instances  in  which  they  usually 
concur,  the  one  proceeds  without  the  other.  I  might  quote  many 
examples  of  this.  I  will  choose  one  or  two  which,  at  the  same  time, 
may  illustrate  some  other  striking  facts. 

Thus,  for  examples  in  which  development  was  checked  and  growth 
proceeded  even  beyond  its  normal  limits,  we  may  examine  some  of  the 
numerous  malformed  hearts  in  the  Museum.  One  among  them  presents 
only  a  single  cavity ;  no  partition  has  been  developed  between  its 
auricles  or  its  ventricles ;  it  is,  in  respect  of  its  development,  like  the 
heart  of  a  foetus  in  the  second  month :  but  though  its  development  was 
checked  thus  early,  its  growth  continued,  and  it  has  more  than  the 
average  size  of  the  hearts  of  children  of  the  same  age.  In  another, 
development  was  arrested  at  a  later  period,  when  the  septum  of  the 
ventricles  was  incompletely  formed ;  the  patient  lived  eleven  years  after 
birth ;  the  development  made  no  further  progress,  but  the  growth  passed 
its  ordinary  bounds. 

And,  once  more,  for  instances  in  which  the  development  was  normal 
and  growth  abnormal,  you  may  examine  such  skeletons  as  those  of 
0' Byrne  the  giant,  and  of  Madlle.  Cracami  the  dwarf,  in  the  Physio- 
logical Museum.  The  one  is  eight  feet  high,  the  other  only  twenty 
inches ;  but  if  you  compare  these  with  the  model  skeletons  which  stand 


ITS    NATURE,    PURPOSE,    AND    CONDITIONS.  27 

beside  them,  you  will  not  find  in  the  one  a  defect,  or  in  the  other  an 
excess,  of  development ;  the  dwarf  has  not  less  than  all  the  characteristic 
human  forms,  the  giant  has  no  more ;  but  the  one  is  defective,  the 
other  is  excessive,  in  its  bulk ;  the  growth  alone  has  been  erroneous  in 
both. 

It  is,  then,  in  the  change  to  a  higher  state  of  former  composition  that 
development  differs  from  growth,  the  second  mode  of  the  formative 
process.  In  mere  growth  no  necessarj  change  of  form  or  composition 
occurs  :  parts  only  increase  in  weight,  and,  usually,  in  size.  In  growth, 
there  is  an  addition  of  quantity,  but  no  improvement  in  the  quality,  of 
a  part;  the  power  of  the  groAving  part  increases  with  the  growth,  but 
is  only  more  of  the  same  power ;  so,  in  the  attainment  of  manhood,  the 
heart  of  the  boy  having  all  its  necessary  parts,  and  all  well/  formed, 
acquires  perfection  by  acquiring  greater  bulk,  and,  therewith,  greater 
power. 

Lastly,  in  the  formative  process,  as  it  is  normally  manifested  in  the 
adult,  i.  e.  in  ordinary  assimilation  or  maintenance,  parts  only  preserve 
their  status.  No  perceptible  change  of  size  or  weight  ensues,  no  change 
of  form  or  composition ;  sameness  is  maintained  through  the  regular 
formation  of  new  parts  in  the  place  of  those  which,  in  the  ordinary 
course  of  life,  are  impaired,  or  die.  Such  are  the  methods  of  the  forma- 
tive process  in  the  healthy  nutrition  of  organs.  I  shall  have  to  show  in 
future  lectures  that  some  of  the  terms  just  used  are  in  a  measure  con- 
ventional, and  arbitrary  ;  that  some  instances  of  what  we  call  develop- 
ment, e.  g.,  that  of  cartilage  into  bone,  are  not  in  every  sense  justly  so 
named ;  and  that  the  sameness,  which  is  maintained  in  the  adult  body, 
fades  into  a  gradual  degeneration.  But,  for  the  present,  the  terms  that 
I  have  used  may  suffice.  It  is  convenient,  also,  to  think  of  the  three 
methods  of  formation,  as  if  each  might  be  separately  manifested ;  yet, 
probably,  they  are  often  concurrent ;  the  maintenance  of  some,  or  of 
many,  whole  organs  being  achieved  only  by  the  constant  development 
and  growth  of  new  elemental  structures  in  the  place  of  those  that  are 
out-worn. 

Now,  for  the  elucidation  of  this  maintenance  of  parts  by  the  constant 
mutation  of  their  elements,  let  me  speak — 

1st.  Of  the  sources  of  impairment,  or,  if  I  may  so  say,  of  the  wear 
and  tear,  to  which  every  part  of  the  body  appears  to  be  subject. 

2dly.  Of  the  conditions  necessary  for  the  healthy  state  of  the  process 
of  nutrition  by  which  the  results  of  the.  wear  and  tear  are  repaired. 

3dly.  Of  the  formative  process  itself. 

First,  then,  the  deterioration  of  the  body  may  be  traced  to  two 
principal  sources ;  namely,  the  Aveariug  out  of  parts  by  exercise,  and 
the  natural  deterioration  or  death  of  the  elemental  structures  of  every 
part  or  organ,  independent  of  the  decay  or  death  of  the  whole  body, 
after  a  certain  period  of  existence. 

From  the  first  of  these,  the  wearing-out  of  parts  by  exercise,  it  is 


28  NUTRITION: 

probable  that  no  tissue  or  part  enjoys  immunity.  For  although,  in  all 
the  passive  apparatus  of  the  body — the  joints,  bones,  ligaments,  elastic 
vessels,  and  the  like — much  of  the  beauty  of  their  construction  consists 
in  the  means  applied  to  diminish  the  effects  of  the  friction,  and  the 
various  pressures  and  stretchings  to  which  they  are  subject,  yet,  in 
enduring  these  at  all,  they  must  be  impaired,  and,  in  the  course  of 
years,  must  need  renewal.  In  these  parts,  undoubtedly,  the  waste  by 
■  exercise  is  much  less  than  that  of  the  more  active  organs,  such  as  the 
muscles,  and,  perhaps,  the  nervous  system.  With  regard  to  the  muscles, 
it  is  clear  that  chemical  decomposition  and  consumption  of  their  substance 
attend  their  continued  action.  Such  action  is  always  followed  by  the 
increased  discharge  of  urea,  carbonic  acid,  and  water.  The  researches 
of  Helmholtz*  show,  that  the  muscles  themselves,  after  long-repeated 
contractions,  are  changed  in  chemical  composition ;  those  of  G.  V. 
Liebigt  have  detected  and  measured  the  formation  of  carbonic  acid  in 
them  during  similar  contractions.  And  further,  Du  Bois  Reymond  has 
recently  shown, |  that  the  muscular  juice,  which,  so  long  as  the  muscles 
are  in  a  state  of  quiescence,  possesses  a  neutral,  or  faintly  alkaline, 
reaction,  becomes,  after  they  have  been  violently  exercised,  decidedly 
acid. 

We  have  nearly  similar  evidence  of  the  impairment  of  the  nervous 
system  by  prolonged  exertion  of  its  power.  We  have,  indeed,  no  proof 
that  the  simple  conduction  of  an  impression  through  a  nervous  cord  can 
affect  in  any  way  its  composition  or  its  structure  ;  but  the  abundance  of 
phosphates  occasionally  discharged  with  the  urine,  after  great  mental 
exertion,  shows  that  the  various  acts  of  the  mind  impair  the  brain 
through  which  they  are  manifested.  To  this  point  tend,  also,  the 
researches  of  Dr.  Bence  Jones,§  who  has  shown  that  the  excretion  by 
the  kidneys  of  a  large  quantity  of  phosphatic  salts  is  usual  in  acute 
inflammation  of  the  brain.  And  to  this  conclusion,  that  mental  exercise, 
whether  perceptive  or  active,  impairs  the  structure  of  the  brain,  we 
might  be  led  by  our  sensations  and  by  our  knowledge  of  the  nature  of 
the  Mind.  For  to  the  principle,  the  immaterial  thing,  we  cannot  ascribe 
a  weariness  ;  it  cannot  be  obnoxious  to  waste  or  to  decay ;  mental  fatigue 
is  only  what  the  Mind  feels  of  an  impaired  state  of  the  brain,  and  the 
recovery  from  what  we  call  a  weary  mind  is  the  restoration,  not  of  the 
Mind  itself,  but  of  the  organs  which  it  feels,  which  connect  it  with  the 
external  world,  and  in  which,  during  tranquil  sleep,  the  reparative 
nutrition  goes  on  undisturbed.    , 

It  is,  further,  probable  that  no  part  of  the  body  is  exempt  from  the 
second  source  of  impairment ;  that,  namely,  which  consists  in  the  natu- 
ral death  or  deterioration  of  the  parts  (independent  of  the  death  or 

*  Miiller's  Archiv,  1845,  p.  72.  f  Ibid.  1850,  p.  393. 

'      J  Monat's  Bericht  der  Akad:  der  Wissen:  zu  Berlin,  1860,  p.  288. 
§  Med.  Chir.  Trans,  vol.  xxx,  p.  20. 


ITS    NATURE,    PURPOSE,    AND    CONDITIONS.  29 

decay  of  the  whole  body)  after  a  certain  period  of  their  life.  It  may 
be  proved,  partly  by  demonstration,  and  partly  by  analogy,  that 
each  integral  or  elemental  part  of  the  body  is  formed  for  a  certain 
natural  period  of  existence  in  the  ordinary  conditions  of  active  life,  at 
the  end  of  which  period,  if  not  previously  destroyed  by  outward  force 
or  exercise,  it  degenerates  and  is  absorbed,  or  dies  and  is  cast  out ; 
needing,  in  either  case,  to  be  replaced  for  the  maintenance  of  health.* 

The  simplest  examples  that  I  can  adduce  of  this,  are  in  the  hair  and 
teeth  ;  and  in  the  process  which  I  shall  describe  and  illustrate  with  the 
annexed  diagram,  we  seem  to  have  an  image  in  which  are  plainly 
marked,  though,  as  it  were,  in  rough  outline,  all  the  great  features  of 
the  process  by  which  certain  tissues  are  maintained. 

An  eyelash  which  naturally  falls,  or  which  can  be  drawn  out  without 
pain,  is  one  that  has  lived  its  natural  time,  and  has  died,  and  been 
separated  from  the  living  parts.  In  its  bulb  such  a  one  will  be  foimd 
very  different  from  those  that  are  still  living  in  any  period  of  their 
age.  In  the  early  period  of  the  growth  of  a  dark  eyelash,  we  find  its 
outer  end  almost  uniformly  dark,  marked  only  with  darker  short  linear 
streaks,  and  exhibiting  no  distinction  of  cortical  and  medullary  sub- 
stance. Not  far  from  its  end,  however,  this  distinction  is  plainly 
marked ;  dark  as  the  cortical  part  may  be,  the  medullary  appears  like 
an  interior  cylinder  of  much  darker  granular  substance  :  and  in  a  young 
hair  this  condition  is  continued  down  to  its  deepest  part,  where  it  en- 
larges to  form  the  bulb.  (Fig.  1,  A.)  Now  this  enlargement,  which  is 
of  nearly  cup-like  form,  appears  to  depend  on  the  accumulation  of 
round  and  plump  nucleated  cells,  which,  according  to  their  position, 
are  either,  by  narrowing  and  elongation,  to  form  the  dry  fibro-cells  of 
the  outer  part  of  the  growing  and  further  protruding  shaft,  or  are  to  be 
transformed  into  the  air-holding  cells  of  the  medullary  portion.  At 
this  time  of  most  active  growth,  both  cells  and  nuclei  contain  abundant 
pigment-matter,  and  the  whole  bulb  looks  nearly  black.  The  sources 
of  the  material  out  of  which  the  cells  form  themselves  are,  at  least, 
two  ;  namely,  the  inner  surface  of  the  sheath,  or  capsule,  which  en- 
velopes the  hair,  and  the  surface  of  the  vascular  pulp,  which  fits  in  a 
conical  cavity  in  the  bottom  of  the  hair-bulb. 

Such  is  the  state  of  parts  so  long  as  the  growing  hair  is  all  dark. 
But,  as  it  approaches  the  end  of  its  existence,  it  seems  to  give  tokens 
of  advancing  age,  by  becoming  gray.  (Fig.  1,  b,  c.)  Instead  of  the 
almost  sudden  enlargement  at  its  bulb,  the  hair  only  swells  a  little,  and 
then  tapers  nearly  to  a  point ;  the  conical  cavity  in  its  base  is  con- 
tracted, and  hardly  demonstrable,  and  the  cells  produced  on  the  inner 

*  Hunter  (Works,  vol.  iii,  p.  495),  and  Treviranus  (Biologie,  b.  iii,  482),  may  be  thought 
to  have  had  some  insight  into  this  important  law;  but  the  merit  of  having  first  maintained 
in  terms  nearly  similar  to  the  above,  and  as  more  than  an  hypothesis,  that  "  each  part  of  the 
organism  has  an  individual  life  of  its  own,"  and  "  a  limited  period  of  existence,"  belongs  to 
Dr.  Carpenter. — Principles  of  Human  Physiology,  3d  edit.  p.  623. 


30 


NUTRITION: 


surface  of  the  capsule  contain  no  particle  of  pigment.  Still,  for  some 
time  it  continues  thus  to  live  and  grow,  and  we  find  that  the  vigor  of 
the  conical  pulp  lasts  rather  longer  than  that  of  the  sheath  or  capsule ; 


Fiff.  1. 


for  it  continues  to  produce  pigment-matter  some  time  after  the  cortical 
substance  of  the  hair  has  been  entirely  white,  and  it  is  still  distinct, 
because  of  the  pigment-cells  covering  its  surface. 

At  length  the  pulp  can  be  no  longer  discerned,  and  uncolored  cells 
alone  are  produced,  and  maintain  the  latest  growth  of  the  hair.  With 
these  it  appears  to  grow  yet  some  further  distance,  for  we  see  traces  of 
their  elongation  into  fibres  or  fibro-cells,  in  lines  running  from  the  inner 
surface  of  the  capsule  inwards  and  along  the  surface  of  the  hair ;  and 
we  can  always  observe  that  the  dark  column  of  medullary  air-containing 
substance  ceases  at  some  distance  above  the  lower  end  of  the  contracted 
hair-bulb,  (c,  d.) 

The  end  of  all  is  the  complete  closure  of  the  conical  cavity  in  which 
the  hair-pulp  was  lodged  ;  the  cessation  of  the  production  of  new  cells  ; 
and  the  consequent  detachment  of  the  hair  as  a  dead  part,  which  now 
falls  by  the  first  accident ;  falls,  sometimes,  quite  bare  and  smooth  on 
the  whole  surface  of  its  white  bulb,  but  sometimes  bringing  with  it  a 
layer  of  cells  detached  from  the  inner  surface  of  the  capsule,  (d.) 

Such  is  the  life  of  a  hair  and  such  its  death ;  which  death,  you  see, 
is  natural,  spontaneous,  independent  of  exercise,  or  of  any  mechanical 
external  force,  the  natural  termination  of  a  certain  period  of  life.  Yet, 
before  it  dies,  provision  is  made  for  its  successor ;  for  when  its  growth 
is  failing,  you  often  find,  just  below  the  base  of  the  old  hair,  a  dark 


ITS    NATURE,    PURPOSE,    AND    CONDITIONS.  31 

spot,  the  germ  or  young  pulp  of  the  new  one  ;  it  is  covered  with  cells 
containing  pigment,  and  often  connected  by  a  series  of  pigment-cells 
with  the  old  pulp  or  capsule.  (Fig.  1,  c.)  And  this  appears  to  be 
produced  by  an  increase  in  the  growth  of  the  cells  at  the  bottom  of  the 
hair-follicle,  which  cells  Kolliker's  observations  have  shown  to  be  de- 
rived partly  from  the  soft  round  cells  of  the  hair-bulb,  and  partly  from 
the  adjacent  outer  root-sheath.  By  the  subsequent  elongation  and 
differentiation  of  these  cells  the  new  hair  is  formed. 

I  believe  that  we  may  assume  an  intimate  analogy  between  the  pro- 
cess of  successive  life  and  death,  which  is  here  shown,  and  that  which 
is  believed  to  maintain  the  ordinary  nutrition  of  a  part.  It  may  be 
objected,  indeed,  that  the  death  and  casting-out  of  the  hair  cannot  be 
imitated  in  internal  parts  ;  but  we  are  not  without  an  example  in  which 
the  absorption  of  a  worn-out  internal  particle  is  exactly  imitated  in 
larger  organs,  at  the  end  of  their  appointed  period  of  life.  I  adduce 
the  instance  of  the  deciduous  or  milk-teeth. 

We  trace  each  of  these  developed  from  its  germ,  then  each,  having 
gained  its  due  perfection,  retains  for  a  time  its  perfect  state,  and  still 
lives,  though  it  dpes  not  grow.  But  at  length,  as  the  new  tooth  comes, 
the  deciduous  tooth  dies,  coincidently,  not  consequently ;  or  rather  the 
crown  of  the  old  tooth  dies,  and  is  cast  out  like  the  dead  hair ;  while 
its  fang,  and  the  vascular  and  nervous  pulp  degenerate,  and  are  ab- 
sorbed. It  is  here  especially  to  be  observed,  that  the  degeneration  is 
accompanied  by  some  spontaneous  transformation  of  the  fang ;  for  it 
could  not  be  absorbed,  unless  it  were  first  so  changed  as  to  be  soluble. 
And  it  is  degeneration,  not  death,  which  precedes  its  removal ;  for 
when  a  tooth-fang  really  dies,  as  that  of  the  second  tooth  does  in  old 
age,  then  it  is  not  absorbed,  but  is  cast  out  entire,  as  a  dead  part. 

Such,  or  nearly  such,  it  seems  almost  certain,  is  the  process  of  nutri- 
tion everywhere :  these  may  be  taken  as  types  of  what  occurs  in  other 
parts ;  for  these  are  parts  of  complex  organic  structure  and  composi- 
tion, and  the  teeth-pulps,  which  are  absorbed  as  well  as  the  fangs,  are 
very  vascular  and  sensitive,  and  therefore,  we  may  be  nearly  sure,  are 
conformed  to  only  the  same  laws  as  prevail  in  all  equally  organized 
parts. 

Nor  are  these  the  only  instances  that  might  be  adduced.  We  see 
the  like  development,  persistence  for  a  time  in  the  perfect  state,  death, 
and  discharge,  in  all  the  varieties  of  cuticles  ;  and  in  the  epidermis  we 
have,  as  in  the  teeth,  an  evidence  of  chemical  change  in  the  old  cells, 
in  the  very  different  influence  which  acetic  acid  and  potash  exercise  on 
them  and  on  the  younger  cells,  making  these  transparent,  but  leaving 
them  scarcely  changed. 

These  things,  then,  seem  to  show  that  the  ordinary  course  of  each 
elementary  organ  in  the  body,  after  the  attainment  of  its  perfect  state 
by  development  and  growth,  is,  to  remain  in  that  state  for  a  time  ;  then, 
independently  of  the  death  or  decay  of  the  whole  body,  and,  at  least, 


32  NUTRITION: 

in  a  great  measure  independently  of  its  own  exercise  or  exposure  to 
external  violence,  to  die  or  to  degenerate ;  and  then,  being  cast  out  or 
absorbed,  to  make  way  for  its  successor.* 

It  appears,  moreover,  very  probable,  tbat  the  length  of  life  which 
each  part  is  to  enjoy  is  fixed  and  determinate,  though,  of  course,  in 
some  degree,  subject  to  accidents,  which  may  shorten  it,  as  sickness 
may  prevent  death  through  mere  old  age ;  and  subject  to  the  expendi- 
ture of  life  in  the  exercise  of  function.  I  do  not  mean  that  we  can  as- 
sign, as  it  is-  popularly  supposed  we  can,  the  time  that  all  our  parts 
will  last ;  nor  is  it  likely  that  all  parts  are  made  to  last  an  equal  time, 
and  then  to  be  changed.  The  bones,  for  instance,  when  once  completely 
formed,  probably  last  longer  than  the  muscles  and  other  softer  tissues. 
But  when  we  see  that  the  life  of  certain  parts  is  of  determined  length, 
whether  they  be  used  or  not,  we  may  assume,  from  analogy,  the  same 
of  nearly  all. 

For  instance,  the  deciduous  human  teeth  have  an  appointed  dura- 
tion of  life ;  not,  indeed,  exactly  the  same  in  all  persons,  yet,  on  the 
whole,  fixed  and  determinate.  So  have  the  deciduous  teeth  of  other 
animals.  And  in  all  those  numerous  instances  of  periodical  moulting, 
of  shedding  of  the  antlers,  of  the  entire  desquamation  of  serpents,  and 
of  the  change  of  plumage  in  birds,  and  of  the  hair  in  mammalia ;  what 
means  all  this,  but  that  these  organs  live  their  severally  appointed 
times,  degenerate,  die,  are  cast  away,  and  in  due  time  are  replaced  by 
others ;  which  in  their  turn  are  to  be  developed  to  perfection,  to  live 
their  life  in  the  mature  state,  and  to  be  cast  off?  We  may  discern  the 
same  laws  of  life  in  some  elementary  structures ;  for  example,  in  the 
blood-corpuscles,  of  which  a  first  set,  formed  from  embryo-cells,  disap- 
pears at  a  certain  period  in  the  life  of  the  embryo,  being  replaced  and 
superseded  by  a  second  set  formed  probably  from  lymph  and  chyle  cor- 
puscles. And  in  these,  also,  we  may  see  an  example  of  the  length  of 
life  of  elemental  parts  being  determined,  in  some  measure,  by  their  ac- 
tivity in  function  ;  for  if  the  development  of  the  tadpole  be  retarded,  by 
keeping  it  in  a  cold,  dark  place,  and  if,  in  this  condition,  the  function 
of  the  first  set  of  blood-corpuscles  be  slowly  and  imperfectly  discharged, 
they  will  remain  unchanged  for  even  many  weeks  longer  than  usual ; 
their  individual  life  will  be  thus  prolonged,  and  the  development  of  the 
corpuscles  of  the  second  set  will  be,  for  the  same  time,  postponed.f 

The  force  of  these  facts  is  increased  by  the  consideration  of  the  exact 
analogy,  the  almost  identity,  of  the  processes  of  secretion  and  nutrition  ; 
for  in  no  instance  is  the  fact  of  this  limited  life  of  individual  parts  more 

*  It  is  not  intended  to  be  implied  in  the  above  paragraph,  that  in  all  the  completely 
formed  tissues,  such  a  bodily  removal  and  replacement  of  whole  structures  take  place  as 
we  see  in  the  epithelium  cells.  In  the  bones,  nervous  textures,  and  muscular  fibres,  for  ex. 
ample,  the  changes  are  undoubtedly  molecular,  the  structure  remaining,  though  the  materials 
which  compose  it  are  renewed. 

t  See  Kirkes's  Physiology,  pp.  63  and  298,  4th  ed. 


ITS    NATURE,    PURPOSE,   AND    CONDITIONS.  33 

clearly  shown  than  in  the  gland-cells,  by  which  periodical  secretions 
are  elaborated.  The  connecting  link  between  such  gland-cells  and  the 
most  highly  organized  parts,  as  well  as  a  manifest  instance  of  determi- 
nate length  of  life  and  natural  death,  is  found  in  the  history  of  the  ova. 
These  attain  their  maturity  in  fixed  successive  periods  of  days  :  they 
are  separated  (as  the  materials  of  several  secretions  are)  while  yet  living, 
and  with  a  marvellous  capacity  of  development,  if  only  they  be  impreg- 
nated during  the  few  days  of  life  that  remain  to  them  after  separation ; 
but  if  these  days  pass,  and  impregnation  is  not  effected,  they  die,  and  are 
cast  out  as  impotent  as  the  merest  epithelial  cell.* 

Now  from  these  cases  it  is  not  by  a  far-fetched  analogy  that  we  as- 
sume the  like  mortality  in  all  other  tissues,  and  that  this  is  the  princi- 
pal source  of  impairment,  and  of  change  for  the  worse,  which  every 
part  of  the  body  has  within  itself,  even  in  the  most  perfect  state,  and 
in  the  conditions  most  favorable  to  life.  And  I  may  anticipate  a  future 
subject  of  consideration,  by  saying  that  the  application  of  these  truths 
is  of  some  importance  in  practical  pathology  ;  inasmuch  as  the  results 
of  this  degeneration  of  parts  at  the  close  of  their  natural  term  of  life, 
may  be  mingled  with  the  effects  of  all  the  morbid  processes  by  which 
the  natural  nutrition  of  a  part  is  hindered  or  perverted.  Hence,  at 
least  in  part,  the  long-continuing  or  permanent  loss  of  power  in  an 
organ  (say  a  muscle)  which  has  been  disused,  or  has  been  the  seat  of 
inflammation.  This  loss  is  not  wholly  due  to  a  primary  disease  of  the 
fibre  ;  in  part,  it  is  because  the  inflammatory  process  and  the  organiza- 
tion of  the  morbid  exudation  exclude  the  ordinary  process  of  nutrition  ; 
and  the  muscular  fibres,  which  now,  in  the  ordinary  course  of  life,  de- 
generate, are  not  replaced,  or  are  imperfectly  repaired. 

Of  the  results  of  these  natural  and  unrepaired  degenerations  of  tis- 
sues I  shall  speak  more  hereafter.  Let  me  now  consider  the  conditions 
undey  which  the  repair  of  parts  thus  deteriorated  is  effected ;  for  it  is 
against  the  effects  of  these  natural  deteriorations  that  the  process  of  nu- 
trition in  the  adult  is  chiefly  directed  ;  and  it  appears  to  be  by  the  dis- 
turbance or  removal  of  certain  necessary  conditions,  more  often  than 
by  any  suspension  or  perversion  of  itself,  that  error  is  engendered  in 
the  process  of  formation.  And,  in  speaking  of  these  conditions  of 
healthy  nutrition,  I  shall  take  leave  occasionally  to  diverge,  even  very 
far,  into  the  consideration  of  certain  points  of  interest  in  the  general 
physiology  of  the  process. 

Doubtless  the  conditions  necessary  to  the  normal  nutrition  of  parts 
are  very  many ;  but  the  chief  of  them  are  these  four : 

*  The  adjustment  of  the  organic  processes  according  to  laws  of  time  has  been  more  fully 
illustrated  in  a  discourse  "  On  the  Chronometry  of  Life,"  delivered  at  the  Royal  Institution, 
April  8,  1859,  an  abstract  of  which  appeared  in  the  Journal  of  their  Proceedings.  Tlie 
subject  has  also  been  considered  in  the  Croonian  Lecture  for  1857  (Proc.  Roy.  Soc,  Lend.), 
to  which  reference  may  be  made  for  a  discussion  of  the  phenomena  of  nutrition,  in  the 
rhythmically  acting  muscles,  heart,  diaphragm,  &c. 


34  NUTRITION: 

1.  A  right  state  and  composition  of  the  blood  or  other  nutritive 
material. 

2.  A  regular  and  not  far  distant  supply  of  such  blood. 

3.  (At  least  in  most  cases)  a  certain  influence  of  the  nervous  system. 

4.  A  natural  state  of  the  part  to  be  maintained. 

And,  first  of  the  right  state  of  the  blood,  I  may  observe  that  I  use 
the  expression  "  right  state" rather  than  "  purity,"  because,  if  the  latter 
be  used,  it  seems  to  imply  that  there  is  some  standard  of  composition  to 
which  all  blood  might  be  referred,  and  the  attainment  of  which  is 
essential  to  health ;  whereas  the  truth  seems  rather  to  be,  that,  from 
birth  onwards,  the  blood  and  tissues  of  each  creature  are  adapted  to  one 
another,  and  to  the  necessary  external  circumstances  of  life,  and  that 
the  maintenance  of  health  depends  on  the  maintenance  and  continual 
readjustment  of  the  peculiarities  on  which  this  exact  adaptation  de- 
pends. 

The  necessity  for  this  right  or  appropriate  state  of  the  blood,  as  a 
condition  of  healthy  nutrition,  involves  of  course  the  necessity  for  the 
due  performance  of  the  blood-making  and  blood- purifying  functions  ;  it 
requires  healthy  digestion,  healthy  respiration,  healthy  excretion.  Any 
one  of  these  being  disturbed,  the  formative  process  in  a  part,  or  in  the 
whole  body,  may  be  faulty,  for  want  of  the  appropriate  material.  But, 
important  as  these  are,  we  must  not  let  the  consideration  of  them  lead 
us  to  forget  that  there  is  something  in  the  blood  itself,  which  is  at  least 
as  essential  to  the  continuance  of  its  right  and  healthy  state  as  these 
are,  and  which  is,  indeed,  often  occupied  in  correcting  the  errors  to 
which  these,  more  than  itself,  are  subject;  I  mean  the  power  of  assimila- 
tion or  maintenance  which  the  blood  possesses,  in  and  for  itself,  as 
perfectly  and  at  least  as  independently  as  any  of  the  tissues.  By  this 
it  is,  that  notwithstanding  the  diversity  of  materials  put  into  the  blood, 
and  the  diversity  of  conditions  in  which  the  functions  ministering  .to  its 
formation  are  discharged,  yet  the  blood  throughout  life  retains,  in  each 
person,  certain  characters  as  peculiar  as  those  of  his  outer  features  for 
the  continual  renewal  of  which  it  provides  appropriate  materials.  And 
by  this  assimilative  power  of  the  blood  it  is  that  the  tissues  are  con- 
tinually guarded ;  for  by  it  many  noxious  substances  introduced  into 
the  blood  are  changed  and  made  harmless  before  they  come  to  the 
tissues  ;  nor  can  any  substance,  introduced  from  without,  produce  dis- 
ease in  an  organ,  unless  it  be  such  a  one  as  can  escape  the  assimilative 
and  excretory  power  of  the  blood  itself. 

In  this  maintenance  is  the  chief  manifestation  of  the  life  of  the  adult 
blood ;  a  life,  in  all  essential  things,  parallel  and  concurrent  with  that 
of  the  tissues.  For  in  the  blood  Ave  may  trace  all  those  which  we 
recognize  as  signs  and  parts  of  life  in  the  solids ;  we  watch  its  develop- 
ment, its  growth,  its  maintenance  by  the  assimilation  of  things  unlike 
itself;  we  find  it  constituting  an  adapted  purposive  part  of  the  organism; 
possessing  organic  structures ;  capable  of  disease  and  of  recovery ;  prone 


ITS  NATURE,  PURPOSE,  AND  CONDITIONS. 


35 


Fie;.  2. 


to  degeneration  and  to  death.  In  all  these  things,  we  have  to  study  the 
life  of  the  blood  as  we  do  that  of  the  solid  tissues ;  the  life,  not  only  of 
the  structures  of  the  blood,  but  of  its  liquid  also ;  and  as,  in  first 
development,  the  blood  and  tissues  are  made,  of  similar  materials,  in 
exact  conformity  with  one  another,  so,  through  later  life,  the  normal 
changes  of  each  concur  to  maintain  a  like  conformity  and  mutual 
adaptation.  I  cannot  now  dwell  on  these  points  ;*  but  they  will  be 
frequently  illustrated  in  the  following  lectures,  and  some  of  them  at 
once,  in  what  I  have  to  say  of  the  precision  of  adjustment  in  which  the 
"right  state"  of  the  blood  consists. 

Notwithstanding  its  possession  of  the  capacity  of  maintenance,  the 
blood  is  subject  to  various  diseases,  in  consequence  of  which  the  nutri- 
tion of  one  or  more  tissues  is  disordered.  The  researches  of  modern 
chemistry  have  detected  some  of  these  changes ;  finding  excesses  or 
deficiencies  of  some  of  the  chief  constituents  of  the  blood,  and  detecting 
in  it  some  of  the  materials  introduced  from  without.  But  a  far  greater 
number  of  the  morbid  conditions  of  the  blood  consist  in  changes, 
from  the  discovery  of  which  the 
acutest  chemistry  seems  yet  far 
distant,  and  for  the  illustration 
and  discussion  of  which  we  can- 
not adopt  the  facts,  though  we 
may  adopt  the  language  and  the 
analogies,  of  chemistry.  It  is  in 
such  diseases  as  these  that  we 
can  best  discern  how  nice  is  that 
refinement  of  mutual  influence, 
how  exact  and  constant  that 
adaptation,  between  the  blood 
and  tissues,  on  which  health  de- 
pends. 

I  know  no  instance  so  well 
adapted  to  illustrate  this  as  the 
examples  of  symmetrical  dis- 
eases. The  uniform  character 
of  such  diseases  is,  that  a  cer- 
tain morbid  change  of  structure 
on  one  side  of  the  body  is  re- 
peated in  the  exactly  corres- 
ponding part  on  the  other  side. 
In  the  lion's  pelvis,  for  example, 
which  is  sketched  in  the  an- 
nexed diagram.   Fig.  2,  from  a 


"  They  formed  the  subject  of  the  course  of  Lectures  delivered  at  the  College  in  1S4S,  an 
abstract  of  part  of  which  is  given  by  Dr.  Kirkes  in  his  "Handbook  of  Physiology,"  p.  61, 
et  seq.  4th  ed. 


36  nutrition: 

specimen  (No.  3030)  in  the  College  Museum,  multiform  as  the  pattern 
is,  in  which  the  new  bone,  the  product  of  some  disease  comparable  with 
a  human  rheumatism,  is  deposited, — a  pattern  more  complex  and  irre- 
gular than  the  spots  upon  a  mat, — there  is  not  one  spot  or  line  on  one 
side  which  is  not  represented,  as  exactly  as  it  would  be  in  a  mirror,  on 
the  other.  The  likeness  has  more  than  daguerreotype  exactness,  and 
was  observed  in  numerous  pairs  of  the  bones  similarly  diseased. 

I  need  not  describe  many  examples  of  such  diseases.  Any  out-pa- 
tient's room  will  furnish  abundant  instances  of  exact  symmetry  in  the 
eruptions  of  eczema,  lepra,  and  psoriasis  ;  in  the  deformities  of  chronic 
rheumatism,  the  paralyses  from  lead  ;  in  the  eruptions  excited  by  iodide 
of  potassium  or  copaiba.  And  any  large  museum  will  contain  exam- 
ples of  equal  symmetry  in  syphilitic  ulcerations  of  the  skull ;  in  rheu- 
matic and  syphilitic  deposits  on  the  tibiffi  and  other  bones ;  in  all  the 
effects  of  chronic  rheumatic  arthritis,  Avhether  in  the  bones,  the  liga- 
ments, or  the  cartilages ;  in  the  fatty  and  earthy  deposits  in  the  coats 
of  arteries. 

Now  these  facts  supply  excellent  evidence  of  the  refinement  of  the 
affinities  which  are  concerned  in  the  formative  process.  Excluding, 
perhaps,  the  cases  of  congenital  defects  that  are  symmetrical,  and  a  few 
which  seem  to  depend  on  morbid  influence  of  the  nervous  system,  it 
may  be  stated  generally,  that  all  symmetrical  diseases  depend  on  some 
morbid  material  in  the  blood.  You  may  find  the  proof  of  this  position 
in  papers  written  simultaneously  by  Dr.  William  Budd  and  myself;* 
and  in  Dr.  Budd's  essay  you  may  find  it  nearly  demonstrated,  by  a 
masterly  discussion  of  the  subject,  that  in  most  of  these  cases,  the 
morbid  material  enters  into  combination  with  the  tissue  which  is  dis- 
eased, or  with  the  organized  product  of  the  morbid  process.  Now  the 
evident  and  applicable  truth  in  all  these  cases  is,  that  the  morbid  sub- 
stance in  the  blood,  be  it  Avhat  it  may,  acts  upon  and  changes  only  cer- 
tain portions  of  what  we  might  suppose  to  be  all  the  very  same  tissue. 
Such  a  substance  fastens  on  certain  islands  on  the  surfaces  of  two 
bones,  or  of  two  parts  of  the  skin,  and  leaves  the  rest  unscathed: 
and  these  islands  are  the  exactly  corresponding  pieces  upon  op- 
posite sides  of  the  body.  The  conclusion  is  unavoidable,  that  these 
are  the  only  two  pieces  that  are  exactly  alike;  that  there  was  less 
affinity  between  the  morbid  material  and  the  osseous  tissue,  or  the 
skin,  or  the  cartilage,  close  by ;  else  it  also  would  have  been  similarly 
diseased.  Manifestly,  when  two  substances  display  different  relations 
to  a  third,  their  composition  cannot  be  identical ;  so  that,  though  we 
may  speak  of  all  bone  or  of  all  skin,  as  if  it  were  all  alike,  yet  there 
are  differences  of  intimate  composition;  and  in  all  the  body  the  only 
parts  which  are  exactly  like  each  other,  in  their  mutual  relation  with 
the  blood,  are  those  which  are  symmetrically  placed  upon  the  opposite 

*  Medico-Chirurg.  Trans,  vol.  xxv. 


ITS    NATURE,    PURPOSE,    AND    CONDITIONS.  37 

sides.  No  power  of  artificial  chemistry  can,  indeed,  detect  the  differ- 
ence ;  but  a  morbid  material  can  :  it  tests  out  the  parts  to  which  it  has 
the  greatest  affinity,  unites  with  these,  and  passes  by  the  rest.* 

I  might  magnify  the  wonder  of  this  truth  by  showing  how  exceed- 
ingly small,  in  some  of  these  cases,  must  be  the  quantity  of  the  morbid 
material  existing  in  the  blood.  But  I  prefer  to  illustrate  a  fact  which 
singularly  corroborates  the  evidence,  afforded  by  symmetrical  diseases, 
of  the  refinement  of  the  operations  of  the  affinities,  if  we  may  so  call 
them,  between  the  blood  and  the  tissues.  The  fact  is  that  of  certain 
blood  diseases  having  "seats  of  election."  For  example,  in  another  lion's 
pelvis  (No.  3024),  diseased  like  that  sketched  above,  not  only  is  the 
morbid  product  just  as  symmetrical,  but  its  arrangement  is  exactly 
similar ;  hardly  a  spot  appears  on  one  pelvis  which  is  not  imitated  on 
the  other.  And  these  are  only  examples  of  a  large  class  of  cases  of 
syphilis,  rheumatism,  and  various  skin  diseases,  of  which  the  general 
character  is,  that  the  disease  is  much  more  apt  to  affect  one  certain  por- 
tion of  a  bone,  or  of  the  skin,  or  of  some  other  tissue,  than  to  attack 
any  other  portion.  We  are  all  in  the  habit  of  using  the  fact  as  an  aid 
in  diagnosis ;  but  we  may  have  overlooked  its  bearing  on  the  physiology 
of  nutrition.  It  proves,  on  the  one  hand,  as  the  cases  of  symmetrical 
diseases  do,  that  the  composition  of  the  several  portions  of  what  we 
call  the  same  tissue  is  not  absolutely  identical ;  if  it  were,  these  diseases 
should  affect  one  part  of  a  bone  or  other  tissue  as  often  as  another  part, 
or  should  affect  all  parts  alike.  And  it  proves,  on  the  other  hand,  a 
constant  similarity,  even  an  identity  of  the  morbid  material  on  which 
each  of  these  diseases  depends,  though  it  be  produced  in  different  indi- 
viduals ;  so  that  we  may  venture  to  predict,  that  whenever  chemistry 
shall  discover  the  composition  of  these  materials,  it  will  be  found  as  con- 
stant and  as  definite  as  the  composition  of  those  inorganic  substances 
which  the  science  has  most  successfully  scrutinized. 

Moreover,  Dr.  William  Budd  has  proved  that,  next  to  the  parts  which 
are  symmetrically  placed,  none  are  so  nearly  identical  in  composition  as 
those  which  are  homologous.  For  example,  the  backs  of  the  hands  and 
of  the  feet,  or  the  palms  and  soles,  are  often  not  only  symmetrically, 
but  similarly  affected  with  psoriasis.     So  are  the  elbows  and  the  knees ; 

*  Some  of  the  differences  here  noticed  are  not  permanent,  but  may  seem  to  depend  on  the 
several  parts  of  a  bone,  or  of  the  skin  of  a  limb  (for  example),  being  in  different  stages  of 
development  or  degeneration.  The  symmetrical  parts  of  the  tissue,  being  exactly  alike,  may 
be  simultaneously  and  equally  affected  by  a  disease,  while  other  parts  of  the  same  remain 
unaffected,  till  in  the  course  of  time,  they  attain,  by  development  or  degeneration,  the  very 
same  condition  as  the  parts  first  affected.  Then,  if  the  morbid  material  still  exist  in  the 
blood,  these  parts  also  become  diseased;  and  so  in  succession  may  nearly  the  whole  of  a 
tissue.  This  view  agrees  very  well  with  the  fact  that  symmetrical  diseases  often  spread, 
and  so  prove  that  a  part  which  in  one  week  or  month  is  not  susceptible  of  the  influence  of  a 
morbid  material,  may  in  the  next,  become  as  susceptible  as  that  which  was  first  affected. 
This  susceptibility,  however,  may  be  due,  not  to  normal  changes,  but  to  the  influence  which 
the  diseased  portion  of  the  tissue  exercises  on  those  around  it. 


68  CONDITIONS    NECESSARY    TO 

and  similar  portions  of  the  thighs  and  the  arms  may  be  found  affected 
with  ichthyosis.  Sometimes  also  specimens  of  fatty  and  earthy  deposits 
in  the  arteries  occur,  in  Avhich  exact  similarity  is  shown  in  the  plan, 
though  not  in  the  degree,  with  which  the  disease  affects  severally  the 
humeral  and  femoral,  the  radial  and  peroneal,  the  ulnar  and  posterior 
tibial  arteries. 

To  conclude,  these  symmetrical  diseases  with  seats  of  election  prove, 

1st.  That  in  the  same  person  the  only  parts  of  any  tissue  which  are 
identical  in  composition  are,  or  may  be,  first,  those  which  occupy  sym- 
metrical positions  on  the  opposite  sides  of  the  body  ;  and  next,  those 
which  are  in  serial  homology. 

2dly.  That  the  portions  of  the  bodies  of  different  individuals  which 
are  identical,  or  most  nearly  so,  in  composition,  are  those  in  exactly 
corresponding  positions. 

3dly.  That  even  in  different  individuals  the  specific  morbid  materials, 
on  which  many  of  the  diseases  of  the  blood  depend,  are  of  identical 
composition. 

It  would  be  foreign  to  my  purpose  to  enter  now  upon  all  the  subjects 
of  interest  which  are  illustrated  by  these  cases.  I  may  refer  you  again 
to'  the  papers  already  mentioned,  especially  to  Dr.  Budd's.  For  the 
present  it  will  be  sufficient  if  I  have  proved  (without  pretending  to  ex- 
plain or  describe)  the  perfect  and  most  minute  exactness  of  the  adapta- 
tion which,  in  health,  exists  between  the  blood  and  all  the  tissues ;  and 
that  certain  inconceivably  slight  disturbances  of  this  adaptation  may 
be  sources  of  disease.  If  this  be  proved,  I  shall  not  fear  to  be  met 
with  an  objection  against  too  great  refinement  in  what  I  shall  next  say 
concerning  some  of  the  means  by  which  that  right  state  of  the  blood, 
which  is  appropriate  to  the  healthy  nutrition  of  all  the  parts,  is  at- 
tained and  preserved. 


LECTURE   II. 

THE    CONDITIONS    NECESSARY   TO    HEALTHY   NUTRITION. 

I  NEED  not  dwell  on  the  physiology  of  the  process  of  digestion, 
absorption,  excretion,  and  others,  which,  on  the  large  scale,  serve  in  the 
development  and  maintenance  of  the  blood.  The  admitted  doctrines 
concerning  these  I  must  assume  to  be  well  known,  while  I  proceed  with 
the  consideration  of  those  minuter  relations  in  which  the  blood  and  the 
several  tissues  exercise  their  mutual  influence,  and  by  which  each  is 
maintained  in  its  right  state.  And,  first,  let  me  endeavor  to  develop 
a  principle,  the  germ  of  which  is  in  the  writings  of  Treviranus.  His 
sentence  is,  that  "  each  single  part  of  the  body,  in  respect  of  its  nutri- 


HEALTHY    NUTRITION.  39 

tion,  stands  to  the  whole  body  in  the  relation  of  an  excreted  substance."* 
In  other  words,  every  part  of  the  body,  by  taking  from  the  blood  the 
peculiar  substances  Avhich  it  needs  for  its  own  nutrition,  does  thereby 
act  as  an  excretory  organ,  inasmuch  as  it  removes  from  the  blood  that 
which,  if  retained  in.it,  would  be  injurious  to  the  nutrition  of  the  rest 
of  the  body.  Thus,  he  says,  the  polypiferous  zoophytes  all  excrete 
large  quantities  of  calcareous  and  siliceous  earths.  In  those  which 
have  no  stony  skeletons  these  earths  are  absolutely  and  utterly  excreted  ; 
but  in  those  in  which  they  form  the  skeleton,  they  are,  though  retained 
within  the  body,  yet  as  truly  excreted  from  the  nutritive  fluid  and  all 
the  other  parts,  as  if  they  had  been  thrown  out  and  washed  away.  So 
the  phosphates  which  are  deposited  in  our  bones  are  as  effectually  ex- 
creted from  the  blood  and  the  other  tissues,  as  those  which  are  discharged 
with  the  urine. 

But  Treviranus  seems  not  to  have  apprehended  the  full  importance  of 
the  principle  which  he  thus  clearly,  though  so  briefly,  stated;  for  it 
admits,  I  think,  of  far  extension  and  very  interesting  application. 

Its  influence  may  be  considered  in  a  large  class  of  out-growing  tis- 
sues. The  hair,  for  example,  in  its  constant  growth,  serves,  not  only 
local  purposes,  but  for  the  advantage  of  the  whole  body,  in  that,  as  it 
grows,  it  removes  from  the  blood  the  various  constituents  of  its  sub- 
stance which  are  thus  excreted  from  the  body.  And  this  excretory 
ofiice  appears,  in  some  instances,  to  be  the  only  one  by  which  the  hair 
serves  the  purpose  of  the  individual ;  as,  for  example,  in  the  foetus. 
Thus,  in  the  foetus  of  the  seals,  that  take  the  water  as  soon  as  they  are 
born,  and,  I  believe,  in  those  of  many  other  mammals,  though  they  are 
removed  from  all  those  conditions  against  which  hair  protects,  yet  a 
perfect  coat  of  hair  is  formed  within  the  uterus,  and  before,  or  very 
shortly  after,  birth  this  is  shed,  and  is  replaced  by  another  coat  of 
wholly  different  color,  the  growth  of  which  began  within  the  uterus. 
Surely,  in  these  cases,  it  is  only  as  an  excretion,  or  chiefly  as  such,  that 
this  first  growth  of  hair  serves  to  the  advantage  of  the  individual.  The 
lanugo  of  the  human  foetus  is  an  homologous  production,  and  must,  I 
think,  similarly  serve  in  the  economy,  by  removing  from  the  blood,  as 
so  much  excreted  matter,  the  materials  of  which  it  is  composed. 

Further,  I  think  we  may  carry  this  principle  to  the  apprehension  of 
the  true  import  of  the  hair  which  exists  in  a  kind  of  rudimental  state 
on  the  general  surface  of  our  bodies,  and  to  that  of  many  other  perma- 
nently rudimental  organs,  such  as  the  mammary  glands  of  the  male 
and  others.  For  these  rudimental  organs  certainly  do  not  serve,  in  a 
lower  degree,  the  same  purposes  as  are  served  by  the  homologous  parts 

*  Die  Erschein :  unci  Gesetze  des  organischen  Lebens,  B.  I,  p.  401.  In  an  article  on 
hereditary  influences,  in  the  Westminster  Review,  July,  1  856,  and  in  his  work  on  the  Physi- 
ology of  Common  Life,  vol.  i,  p.  286,  Mr.  G.  H.  Lewes  states  that  C.  F.  Wolff,  and  not  Tre- 
viranus, was  the  originalexpositor  of  the  doctrine  of  complemental  nutrition. — See  Theoria 

Generationis,  1759. 


40  CONDITIONS    NECESSARY    TO 

whicli  are  completely  developed  in  other  species,  or  in  the  other  sex. 
To  say  they  are  useless,  is  contrary  to  all  we  know  of  the  absolute 
perfection  and  all-pervading  purpose  of  Creation :  to  say  they  exist 
merely  for  the  sake  of  conformity  with  a  general  type  of  structure, 
seems  unphilosophical,  while  the  law  of  the  unity  of  organic  types  is, 
in  larger  instances,  not  observed,  except  when  its  observance  contri- 
butes to  the  advantage  of  the  individual.  Rather,  all  these  rudimental 
organs  must,  as  they  grow,  be  as  excretions,  serving  a  definite  purpose 
in  the  economy,  by  removing  their  appropriate  materials  from  the  blood, 
and  leaving  it  fitter  for  the  nutrition  of  other  parts,  or  by  adjusting 
the  balance  which  might  else  be  disturbed  by  the  formation  of  some 
other  part.  Thus  they  minister  to  the  self-interest  of  the  individual, 
while,  as  if  for  the  sake  of  wonder,  beauty,  and  perfect  order,  they 
are  conformed  with  the  great  law  of  the  unity  of  organic  types,  and 
concur  with  the  universal  plan  observed  in  the  construction  of  organic 
beings. 

And  again, — the  principle  that  each  organ,  while  it  nourishes  itself, 
serves  the  purpose  of  an  excretion,  has  an  application  of  peculiar  inte- 
rest in  the  history  of  development.  For  if  it  be  influential  when  all  the 
organs  are  already  formed,  and  are  only  growing  or  maintaining  them- 
selves, much  more  will  it  be  so  when  the  several  organs  are  successively 
forming.  At  this  time,  as  each  nascent  organ  takes  from  the  nutritive 
material  its  appropriate  constituents,  it  will  co-operate  with  the  gradual 
self-development  of  the  blood,  to  induce  in  it  that  condition  which  is 
essential  or  most  favorable  to  the  formation  of  the  organs  next  in  order 
to  be  developed. 

The  importance  of  this  principle  will  the  more  appear  if  we  connect 
with  it  another,  equally  characteristic  of  the  minuteness  of  the  relation 
between  the  blood  and  the  tissues,  namely,  that  the  existence  of  certain 
materials  in  the  blood  may  determine  the  formation  of  structures  in 
which  they  may  be  incorporated. 

This  seems  to  be  established  as  a  general  law  in  pathology,  by  the 
cases  in  which  diseased  structures  evidently  incorporate  materials  that 
had  their  origin  or  previous  existence  in  the  blood.  Such  are  most  of 
those  inoculable  and  other  blood-diseases  in  which  morbid  organisms  are 
produced;  as  vaccinia,  variola,  chancre,  glanders,  &c.  The  same  law 
may  be  made  very  probable  in  physiology  also.  Eor  example,  when 
one  kidney  is  destroyed,  the  other  often  becomes  much  larger,  does 
double  work,  as  it  is  said ;  and  the  patient  does  not  suflFer  from  the 
retention  of  urine  in  the  blood  ;  the  full  meaning  of  which  (a  well- 
known  fact,  and  not  without  parallel)  may  be  thus  expressed :  The  prin- 
cipal constituents  of  the  urine  are,  we  know,  ready  formed  in  the  blood, 
and  are  separated  through  the  kidneys  by  the  development,  growth,  and 
discharge  of  the  contents  of  the  renal  cells  in  which  they  are,  for  a 
time,  included.  Now,  when  one  kidney  is  destroyed,  there  must  for  a 
time  be  an  excess  of  the  constituents  of  urine  in  the  blood ;  for  since 


HEALTHY    NUTRITION.  41 

the  separation  of  urine  is  not  mere  filtration,  the  other  kidney  cannot 
at  once,  and  without  change  of  size,  discharge  a  double  quantity.  What, 
then,  happens  ?  The  kidney  grows  ;  more  renal  cells  develop,  and  dis- 
charge, and  renew  themselves ;  in  other  words,  the  existence  of  the 
constituents  of  the  urine  in  the  blood  that  is  carried  to  every  part  deter- 
mines the  formation  of  the  appropriate  renal  organs  in  the  one  appro- 
priate part  of  the  body. 

An  analogous  fact  is  furnished  by  the  increased  formation  of  adipose 
tissue  in  consequence  of  the  existence  of  abundant  hydrocarbon  princi- 
ples in  the  blood.  Another,  bearing  on  the  same  point,  though  not  ad- 
mitting of  definite  description,  is  the  influence  exercised  by  various  diets 
in  favoring  the  especial  growth  of  certain  tissues ;  as  the  muscles,  the 
bones,  the  hair,  or  the  wool.  Similar  facts  are  yet  more  evident  in  the 
cultivation  of  vegetables,  to  which  various  materials  are  supplied,  in  the 
assurance  that  certain  corresponding  tissues  will  be  consequently 
formed.  And  an  evident  illustration  of  the  same  principle  is  in  the 
abundant  formation  of  fruit  on  a  branch  in  which  the  matured  sap  has 
been  made  to  accumulate  by  ringing. 

I  add  again,  on  this  point,  as  on  a  former  one,  that  the  case  as  con- 
cerning nutrition  is  remarkably  corroborated  by  the  observation  of  simi- 
lar facts  in  instances  of  secretions.  Thus,  the  excesses  of  albuminous 
materials  taken  in  food,  if  they  be  not  incorporated  in  the  more  highly 
organized  tissues,  are  excreted ;  that  is,  they,  or  the  materials  into 
which  they  are  transformed,  enter  into  the  construction  of  the  transient 
tissue  of  the  kidney  or  some  excretory  organ.  The  constituents  of  food 
plainly  as  they  intiuence  the  quantity  and  quality  of  milk,  do  so  only 
by  afi'ecting,  after  their  admission  into  the  blood,  the  formation  of  the 
transient  parts  of  the  mammary  gland-tissue.  Medicines,  such  as  diu- 
retics, that  are  separated  from  the  body  by  only  certain  organs,  are,  for 
a  time,  we  must  believe,  incorporated  in  the  tissues  of  those  organs. 

These  facts  seem  enough  to  make  highly  probable  the  principle  I 
mentioned,  namely,  that  the  existence  of  certain  materials  in  the  blood 
may  determine  the  formation  of  structures  into  the  composition  of  which 
those  materials  may  enter.  At  any  rate,  they  make  it  nearly  certain 
for  the  more  lowly  organized  tissues,  and  for  the  products  of  disease ; 
and  hence,  by  analogy,  we  may  assume  it  for  the  other  tissues.  Even 
for  the  very  highest  we  may  safely  hold  that  a  necessary  condition  of 
their  formation  is  this  previous  existence  of  the  peculiarly  appropriate 
materials  in  the  blood. 

Now,  if  we  combine  these  two  principles — first,  that  the  blood  is  defi- 
nitely altered  by  the  abstraction  of  every  material  necessary  for  the 
nutrition  of  a  part,  and  secondly,  that  the  existence  of  certain  materials 
in  the  blood  induces  the  formation  of  corresponding  tissues,  we  may 
derive  from  them  some  very  probable  conclusions  bearing  on  the  ques- 
tions before  us.  First,  we  may  conclude  that  the  order  in  which  the 
several  organs  of  the  body  appear  in  the  course  of  development,  while 

4 


42  CONDITIONS    NECESSARY    TO 

it  is  conformable  with  the  law  of  imitation  of  the  parent,  and  with  the 
law  of  progressive  ascent  towards  the  higher  grade  of  being,  is  yet  in 
part,  and  in  this  more  directly,  the  result  of  necessary  and  successive 
consequences ;  the  formation  of  one  organ,  or  series  of  organs,  inducing 
or  supplying  a  necessary  condition  for  the  formation  of  others,  by  the 
changes  successively  produced  in  the  composition  of  the  blood,  or  other 
nutritive  material.  In  other  words,  we  may  hold,  in  accordance  with 
these  principles,  that  the  development  of  each  organ  or  system  co-ope- 
rating with  the  self-development  of  the  blood,  prepares  it  for  the  forma- 
tion of  some  other  organ  or  system,  till,  by  the  successive  changes  thus 
produced,  and  by  its  own  development  and  increase,  the  blood  is  fitted 
for  the  maintenance  and  nutrition  of  the  completed  organism. 

Secondly,  I  think  that  these  principles  may  be  applied  to  individual 
instances.  They  may  suggest  that  certain  organs  stand,  in  their 
nutrition,  in  a  complemental  relation  to  each  other ;  so  that  neither  of 
them  can  be  duly  formed  or  maintained  in  healthy  structure,  unless  the 
right  condition  of  the  blood  be  induced  and  preserved  by  the  formation 
of  the  other. 

It  is,  of  course,  very  difficult,  or  even  impossible,  to  find  instances  by 
which  this  theory  of  complemental  nutrition  can  be  proved ;  while, 
really,  we  neither  know  exactly  what  materials  are  necessary  for  the 
formation  of  any  organ,  nor  have  the  means  of  detecting  the  presence 
of  more  than  a  very  few  of  them  in  the  blood.  It  is  very  well  for  the 
discussion  of  certain  parts  of  physiology  to  say,  for  instance,  that  a 
muscle  mainly  consists  of  a  material  like  fibrine ;  but  when  we  are  con- 
sidering the  physiology  of  the  formation  of  organs,  we  must  remember 
that  in  every  muscular  fibre  there  are  at  least  three  different  com- 
pounds,— those  of  the  sarcolemma,  of  the  nucleus,  and  of  the  fibril ;  that 
these  are  all  equally  essential  to  the  formation  of  the  fibre ;  and  that 
we  know  not  the  composition  of  any  one  of  them,  nor  could  detect  the 
absence  of  any  one  of  them  from  the  blood,  though  the  result  of  that 
absence  might  be  to  render  the  formation  of  a  muscular  fibre  impossible. 

But,  though  it  may  lack  direct  evidence,  the  theory  seems,  in  itself, 
probable ;  and  there  are  many  facts  which  we  can  explain  by  it  so  well, 
that  they  become  evidence  for  it :  which  facts,  moreover,  are  fair 
subjects  for  theoretical  explanation,  since,  I  believe,  they  are  admitted 
to  be  as  yet  wholly  unexplained. 

Among  these  is  the  general  fact  that  a  great  change  in  nutrition 
rarely  takes  place  in  one  organ  at  a  time,  but  usually  affects  simultane- 
ously two  or  more  parts,  between  whose  nutrition  there  is  a  manifest 
and  constant  connection,  although  there  is  little  or  no  relation  between 
their  external  functions.  Such,  to  take  an  instance  from  a  large  class, 
is  the  connection  between  the  growth  of  various  appendages  of  the 
integuments,  and  the  development  or  maintenance  of  the  genital  organs. 
This  appears  to  be  a  general  rule.  The  growth  of  the  beard  at  the 
period  of  puberty  in  man,  with  which  we  are  so  familiar,  is  more 


HEALTHY    NUTRITION.  43 

instructively  represented  in  many  animals ;  especially  in  birds.  In 
these,  as  you  know,  at  the  approach  of  every  breeding-time,  the  genital 
organs  begin  to  develop  themselves  for  the  season,  as  in  man  they  do 
for  the  whole  time  of  vigorous  life.  And  commensurately  with  this 
development,  the  plumage  (especially  in  the  male  bird)  becomes  brighter 
and  more  deeply  colored,  both  by  the  growth  of  new  feathers  and  by 
the  addition  of  color  to  the  old  ones.  The  height  and  perfection  of  the 
plumage  are  coincident  with  the  full  development  and  activity  of  the 
reproductive  organs ;  but  as  in  man,  when  the  development  of  the  genital 
organs  is  prevented,  that  of  the  beard  and  all  the  other  external  sexual 
characters  is,  as  a  consequence,  hindered,  so,  in  birds,  when  the  breeding 
season  ends,  and  the  sexual  organs  pass  gradually  into  their  periodic 
atrophy,  at  once  the  plumage  begins  to  assume  the  paler  and  more  sober 
colors  which  characterize  the  barrenness  of  winter. 

So  it  is,  also,  at  least  in  certain  instances,  in  the  mammalia,  of  which 
we  have  interesting  evidence,  in  the  history  of  specimens  presented  to 
the  museum  of  the  College  by  Sir  Philip  Egerton.  These  show  that  if 
a  buck  be  castrated  while  his  antlers  are  growing  and  still  covered  with 
the  velt,  their  growth  is  checked,  they  remain  as  if  truncated,  and 
irregular  nodules  of  bone  project  from  their  surfaces.  Or,  if  the  castra- 
tion be  performed  when  the  antlers  are  full-grown,  these,  contrary  to 
what  Hedi  said,  are  shed  nearly  as  usual  at  the  end  of  the  season ;  but 
in  the  next  season  only  a  kind  of  low  conical  stumps  are  formed,  in  the 
place  of  antlers.* 

I  need  not  multiply  examples  :  it  is  a  general  fact,  that  the  develop- 
ment and  activity  of  the  reproductive  organs  have,  as  a  consequence,  or 
as  a  necessary  coincidence,  a  peculiar  development  and  active  growth 
or  nutrition  of  certain  other  structures ;  which  structures,  therefore, 
form  the  external  sexual  characters,  though  their  external  functions 
stand  in  no  apparent,  often  in  no  conceivable,  connection  with  the 
generation  of  the  species.  The  fact  is  not  hitherto  explained ;  it  is 
explicable  on  the  theory  of  complemental  nutrition,  by  believing  that 
the  materials  which,  in  the  formation  of  these  organs  of  external  sexual 
character,  are  removed  from  the  blood,  leave  or  maintain  the  blood  in 
the  state  necessary  for  the  further  development,  growth,  and  active 
function  of  the  proper  sexual  or  reproductive  organs.  In  other  words, 
I  would  say,  that  where  tAvo  or  more  organs  are  thus  manifestly  con- 
nected in  nutrition,  and  not  connected  in  the  exercise  of  any  external 
office,  their  connection  is  because  each  of  them  is  partly  formed  of 
materials  left  in  the  blood  on  the  formation  of  the  other ;  and  each, 
at  the  same  time  that  it  discharges  its  own  proper  and  external  office, 

*  This  formation  of  imperfect  antlers  may  depend  on  the  accessory  organs  of  reproduction 
being  developed ;  for  these  would  not  necessarily  fail  to  be  developed  because  the  testicles 
were  extirpated.  And  that  the  difference  caused  by  castration  is  not  due  to  the  disturbance 
of  nervous  sympathies,  is  proved  by  the  absence  of  any  similar  effect  when  the  testes  are 
only  transplanted. — See  Berthold  in  Miiller's  Arckiv,  1849,  p.  42. 


44  CONDITIONS    NECESSARY    TO 

maintains  the  blood  in  the  condition  most  favorable  to  the  formation  of 
the  other. 

If  this  theory  be  admissible,  we  may  find  through  it  the  meaning  of 
the  commensurate  development  and  nutrition  of  many  other  organs, 
which  in  their  external  functions  appear  unconnected.  Such  are  the 
concurrent  development  and  activity  of  the  thymus  gland,  and  the  air- 
breathing  organs,  during  the  body's  groAvth  ;  of.  the  thyroid  gland  and 
the  brain  (instances  of  commensurate  development  cited  by  Mr.  Simon);* 
of  the  spleen  and  pancreas  (as  pointed  out  by  Professor  Owen) ;  and,  I 
would  add,  of  the  embryo  and  the  mammary  gland  ;  for  the  same  theory 
may  hold  true  concerning  the  formation  of  certain  organs  which  are, 
finally,  connected  in  their  external  functions. 

In  these,  and  other  like  cases,  I  think  it  will  be  hereafter  proved  that 
the  several  organs  are  in  their  nutrition  complemental,  that  the  forma- 
tion of  each  leads  to  the  production  of  some  material  necessary  for  the 
construction  of  the  other ;  and  that,  as  we  may  be  sure  of  Treviranus' 
law,  in  general, — that  each  organ  of  the  body,  while  it  nourishes  itself, 
is  in  the  character  of  an  excretion  towards  all  the  rest, — so,  we  may  be- 
lieve, more  particularly,  that  certain  organs  are,  mutually,  as  excre- 
tions from  each  other. f 

But,  thirdly,  if  there  be  any  probability  in  the  principles  I  have  en- 
deavored to  illustrate,  they  must  deserve  careful'  consideration  in  the 
pathology  of  the  blood.  I  shall  have  to  illustrate  them  in  this  view  in 
future  lectures.  At  present  I  will  only  suggest  that  if  each  part,  in  its 
normal  nutrition,  is  as  an  excreting  organ  to  the  rest,  then  the  cessa- 
tion, or  perversion,  of  nutrition  in  one  must,  by  no  vague  sympathy, 
but  through  definite  change  in  the  condition  of  the  blood,  afFect  the  nu- 
trition of  the  rest,  and  be  thus  the  source  of  "  constitutional  distur- 
bance." If,  in  health,  there  be  such  a  thing  as  complemental  nutri- 
tion, it  must,  in  disease,  be  the  source  of  many  sympathies  in  nutrition 
between  parts  which  are  not  specially  connected  through  the  nervous 
system.  If  the  condition  of  the  blood  can,  in  favorable  circumstances, 
determine  the  formation  of  organisms  incorporating  its  materials,  we 
may  study  the  characteristic  structures  of  specific  diseases  as  the  evi- 
dences of  corresponding  conditions  of  the  blood,  and  as  organs  which, 
by  removing  specific  materials  from  the  blood,  affect  its  whole  constitu- 
tion, and  either  restore  its  health,  or  produce  in  it  secondary  morbid 
changes. 

*  Essay  on  the  Thymus  Gland  ;  and  Philosophical  Transactions,  1844,  Part  2. 

t  Many  of  the  phenomena,  for  which  the  above  theory  is  offered  as  an  explanation,  would 
L'fl  doubtless  looked  upon  by  Mr.  Darwin,  in  conformity  ■with  his  own  peculiar  views  of  the 
orijiin  of  species,  as  due  to  hereditary  transmission :  many  of  the  structures  having  now  no 
direct  relation  to  the  habits  of  Hfe  of  each  species.  But  as  has  been  pointed  out  by  Profes- 
sor Rolleston,  in  an  able  article  in  the  Natural  History  Review,  1861,  p.  484,  all  of  the  above 
instances  cannot  be  brought  under  that  head,  and  the  explanation  given  in  the  text  is  the  one 
that  is  best  warranted  by  the  present  state  of  our  knowledge. 


HEALTHY    NUTRITION.  45 

The  extent  of  application  that  these  principles  admit  of  will,  I  trust, 
justify  the  distance  to  which  I  may  seem  to  have  diverged  from  my 
starting-point.  Let  me  now  return  to  it,  and  remind  you  that  this  long 
discussion  grew  out  of  the  consideration  of  the  first  condition  necessary 
for  healthy  nutrition, — ^namely,  the  right  state  of  the  blood  ;  a  state 
not  to  be  described  merely  as  purity,  but  as  one  of  exact  adaptation  to 
the  peculiar  structure  and  composition  of  the  individual :  an  adaptation 
so  exact  that  it  may  be  disturbed  by  the  imperfect  nutrition  of  a  single 
organ,  and  that  for  the  maintenance  of  it  against  all  the  disturbing 
forces  of  the  outer  life  of  the  body  nothing  can  suffice  except  continual 
readjustment  by  the  assimilative  power  of  the  blood  itself. 

The  second  condition  of  which  I  spoke  as  essential  to  the  healthy 
process  of  nutrition  is — 

A  regular  supply  of  appropriate  blood  in  or  near  the  part  to  be 
nourished. 

The  proofs  of  the  necessity  of  this  condition  must  be  familiar  to  all. 
Instances  will  at  once  occur  to  your  minds  in  which  too  little  blood 
being  sent  to  a  part  it  has  suffered  atrophy,  or  degeneration  :  others, 
in  which  the  supply  being  wholly  cut  off,  mortification  has  ensued  : 
others,  in  which  the  blood,  being  stagnant  in  a  part,  has  not  efficiently 
contributed  to  its  nutrition. 

If  I  can  give  interest  to  this  part  of  the  subject  at  all,  it  is  only  by 
adducing  interesting  examples  of  the  fact.  Reserving  for  future  lec- 
tures the  examples  of  merely  diminished  and  of  perverted  nutrition,  I 
will  mention  now  only  some  of  the  specimens  in  the  Museums  I  have 
chiefly  studied,  which  illustrate  how  the  process  of  nutrition  is  wholly 
stopped  by  the  absence  or  deficiency  of  fresh  blood. 

One  of  Mr.  Swan's  donations  to  the  College  Museum  (No.  1821)  is 
the  larynx  of  a  man  who  while  in  low  health,  cut  his  throat,  and  suf- 
fered so  great  a  loss  of  blood  that  the  nutrition  became  impossible  in 
one  of  those  parts  to  which  blood  is  with  most  difficulty  sent;  and  before 
he  died,  his  nose  sloughed. 

The  case  is  like  one  which,  you  may  remember,  is  recorded  by  Sir 
Benjamin  Brodie.*  A  medical  man  wished  to  be  bled,  in  a  fit  of  ex- 
ceeding drunkenness ;  and  some  one  bled  him,  bled  him  to  three  pints. 
He  became  very  ill,  and  next  day  both  his  feet  were  mortified  from  the 
extremities  of  the  toes  to  the  instep. 

A  specimen  (No.  141),  presented  by  Mr.  Guthrie,  exhibits  a  morti- 
fied, z.  e.  a  completely  unnourished  leg,  from  a  case  in  which  the  femo- 
ral artery  Avas  obliterated  near  the  groin,  through  disease  of  its  coats. 
The  leg  Avas  amputated  by  Mr.  Guthrie,  with  justifying  success ;  for 
the  stump,  though  cut  at  some  distance  below  the  obliteration  of  the 
artery,  did  not  slough ;  the  collateral  circulation  was  sufficient  for  its 
nutrition ;  and  the  patient,  an  elderly  lady,  died  only  of  exhaustion. 

*  Lectures  on  Pathology  and  Surgery,  p.  350. 


46  CONDITIONS    NECESSARY    TO 

For  a  similar,  and  very  rare  example  of  slougliing  after  the  oblitera- 
tion of  a  main  artery,  I  may  refer  to  the  case  described  by  Mr.  Vin- 
cent, of  a  large  slough  in  the  very  substance  of  one  of  the  hemispheres 
of  the  cerebrum,  in  consequence  of  a  wound  of  the  supplying  common 
carotid,  a  wound  made  by  a  tobacco-pipe  thrust  into  the  bifurcation  of 
the  carotid,  and  nearly  closing  its  channel.* 

A  specimen  in  the  Museum  of  St.  Bartholomew's  Hospital  (Series  i, 
134)  exhibits  an  instance  of  dry  gangrene,  occurring  in  very  unusual 
circumstances.  A  woman,  48  years  old,  died,  under  the  care  of  Mr. 
Earle,  having  received  some  injury  of  the  femur  eighteen  months  before 
death.  Whether  it  were  a  fracture,  or,  indeed,  what  it  was,  cannot  now 
be  said;  but  the  injury  was  followed  by  enlargement  of  that  portion  of 
the  wall  of  the  femur  Avith  which  the  artery  and  vein  are  nearly  in  con- 
tact, as  they  pass  in  the  sheath  of  the  triceps  adductor  muscle.  At 
this  part,  then,  the  vein  is  compressed,  and  the  artery,  though  not  dis- 
tinctly compressed,  appears  to  have  been  hindered  from  enlarging.  The 
consequence  was  dry  gangrene  of  the  leg,  which  slowly  destroyed  life, 
and  which  had  no  other  apparent  cause  than  this. 

And,  lastly,  let  me  refer  to  two  specimens,  which  are  as  interesting 
in  the  history  of  surgery  as  in  pathology.  One  is  a  tibia  and  fibula, 
the  lower  ends  of  which,  together  with  the  whole  foot,  perished  in  con- 
sequence of  the  obstruction  of  the  circulation  by  an  aneurism  in  the 
ham.  It  is  a  Hunterian  specimen  in  the  College  Museum  (No.  710) ; 
and  surely  we  may  imagine  that  sometimes  Mr.  Hunter  would  contem- 
plate it  with  pride  to  think  how  rare  such  things  would  be  in  after- 
times.  In  strong  contrast  is  this  other  specimen :  the  limb  of  a  man 
who  once  had  an  aneurism,  like  the  one  which  in  the  former  case  was 
so  destructive,  and  on  whom  Hunter  was  permitted  to  confer  fifty  years 
of  healthy  life  by  his  operation  of  tying  the  artery  at  a  distance  from 
the  diseased  part.  The  Museum  of  St.  Bartholomew's  owes  this  rare 
specimen  and  most  interesting  relic  to  the  zeal  of  my  colleague,  Mr. 
Wormald.  The  patient  was  the  fourth  on  whom  Mr.  Hunter  performed 
his  operation.  He  was  thirty-six  years  old  at  the  time  ;  and  though 
the  tumor  was  not  large,  yet  the  whole  leg  was  swollen,  the  veins  were 
turgid,  and  he  was  exhausted,  and  in  such  bad  health,  that  the  case 
seemed  desperate;  but  he  recovered,  and  lived,  as  I  have  said,  fifty 
years.  The  artery  was  tied  in  the  sheath  of  the  triceps  muscle ;  and  in 
this  operation,  for  the  first  time,  Mr.  Hunter  did  not  include  the  vein 
in  the  ligature.  He  thus  diminished  exceedingly  the  danger  of  the 
defective  supply  of  arterial  blood.  The  preparation  shows  the  whole 
length  of  the  artery  obliterated,  from  the  origin  of  the  profunda  to  that 
of  the  anterior  tibial,  and  the  aneurismal  sac,  even  after  fifty  years,  not 
yet  removed,  but  remaining  as  a  hard  mass  like  an  olive. f 

*  Medico-Chirurgical  Transactions,  vol.  xxix,  p.  38. 

"I"  The  preparation  is  in  Ser.  13,  Siib-Ser.  F.  No.  4.  The  ease  is  in  the  Transactions  of  a 
Society  for  the  Improvement  of  Medical  and  Surgical  Knowledge,  vol.  i,  p.  138:  and  in 
Hunter's  Works,  vol.  iii,  p.  604. 


HEALTHY    NUTRITION.  47 

Now,  the  supply  of  appropriate  blood,  of  wliicli  these  specimens  prove 
the  necessity,  must  be  in  or  near  the  part  to  be  nourished.  We  cannot 
exactly  say  how  near  it  must  be,  but,  probably,  all  that  is  necessary  is, 
that  the  nutritive  material  should  admit  of  being  imbibed  in  sufficient 
quantity  into  the  substance  of  the  part.  For  imbibition  must  be  re- 
garded as  the  means  by  which  all  parts  supply  themselves  with  nutri- 
tive matter  :  thus  deriving  it  from  the  nearest  bloodvessels,  and  the 
bloodvessels  themselves  being  only  the  channels  by  which  the  materials 
are  brought  near.  The  bloodvessels  thus  serve  alike  for  the  nutrition 
of  the  vascular,  and,  as  we  call  them,  the  non-vascular  parts ;  the 
difference  between  which  parts,  in  this  regard,  is  really  very  little.  For 
in  both  cases  the  bloodvessels  lie  outside  the  textures  to  which  they 
convey  the  nutritive  fluid,  and  though,  in  the  vascular  parts,  this  fluid 
is  carried  in  streams  into  their  interior,  whilst  in  the  non-vascular  it 
flows  only  on  or  near  the  surface,  yet,  in  both  alike,  the  parts  to  be 
nourished  have  to  imbibe  the  nutritive  fluid,  and  the  business  of  forma- 
tion is  outside  the  vessels.  The  distance  between  the  bloodvessels  and 
the  textures  in  the  two  cases  is  thus  simply  a  difi"erence  of  degree. 
Thus  in  a  highly  vascular  glandular  organ,  e.  g.,  a  salivary  gland,  ^he 
bloodvessels  are  separated  from  the  active  secreting  cells  merely  ,  ' 
the  thin  limiting  membrane  of  the  gland-vesicles.  In  a  muscle,  again, 
whilst  the  fibrils  at  the  periphery  of  a  fibre  are  separated  from  the 
bloodvessels  only  by  the  thickness  of  the  sarcolemma,  those  in  the  very 
centre  are  removed  to  a  greater  distance  from  them.  In  the  osseous 
tissue,  when  it  exists  in  thin  layers,  as  in  the  lachrymal  and  turbinated 
bones,  the  bloodvessels  do  not  pass  into  the  interior,  but  lie  in  the 
mucous  membrane  on  the  surface.  On  the  other  hand,  when  it  exists  in 
masses,  as  in  the  stronger  bones,  bloodvessels  run  into  the  Haversian 
canals  in  its  substance.  Thus  the  same  tissue  yields  an  illustration  of 
a  vascular  and  non-vascular  texture.  In  both  forms  of  the  tissue  the 
mode  in  which  the  nutriment  is  obtained  is  the  same ;  in  both  the 
vessels  are  at  some  distance  from  the  texture.  In  adaptation  to  its 
density,  and  consequent  comparative  impermeability,  the  osseous  tissue 
possesses  a  peculiar  system  of  canals  and  spaces,  termed  canaliculi  and 
lacunae,  which  communicate,  not  merely  with  each  other,  but  with  the 
canals  in  which  the  bloodvessels  lie.  Along  these  the  nutritive  fluid 
flows ;  they  bring  it  into  closer  relation  with  the  ultimate  texture,  and 
facilitate  its  imbibition.  In  the  dentine  of  a  tooth  a  corresponding 
system  of  canals  is  met  with,  the  dentine  tubes,  which  convey  the 
nutritive  fluid  not  only  to  the  ivory  itself,  but  to  the  enamel  and  tooth 
bone. 

The  non-vascular  epidermis,  again,  though  no  vessels  pass  into  its 
substance,  imbibes  nutritive  matter  from  those  which  lie  in  the  subjacent 
cutis,  and  maintains  itself  and  grows.  Cartilage,  similarly,  is  nourished 
by  the  bloodvessels  of  the  perichondrium  and  the  adjacent  bone.  The 
cornea,  crystalline  lens,  vitreous  humor,  peripheral  part  of  the  umbi- 


48  CONDITIONS    NECESSARY    TO 

lical  cord,  are  frequently  cited  as  still  more  strongly  marked  examples 
of  non-vascular  parts.  In  most  of  these,  as  well  as  in  the  fully  formed 
tendon,  a  system  of  anastomosing  cells,  the  connective  tissue  corpuscles, 
has  been  of  late  years  described  by  Virchow,  which,  probably,  like  the 
lacunae  and  canaliculi  of  bone,  serve  to  transmit  through  their  com- 
municating processes  the  nutritive  fluid  to  the  more  intimate  parts  of 
the  texture.* 

This  mode  of  nutrition  by  imbibition  in  all  the  forms  of  tissue  it  is 
worth  remembering ;  else  we  cannot  understand  how  the  non- vascular 
tissues,  such  as  the  cornea,  the  hair,  the  articular  cartilages,  and  the 
various  cuticles,  should  be  liable  to  diseases  proper  to  themselves, 
primarily  and  independently.  And,  except  by  thus  considering  the 
subject,  we  shall  not  be  clear  of  the  error  and  confusion  which  result 
from  speaking  of  the  "action  of' vessels,"  as  if  the  vessels  really  made 
and  unmade  the  parts.  We  have  no  knowledge  of  the  vessels  as  any- 
thing but  carriers  of  the  materials  of  nutrition  to  and  fro.  They  only 
convey  and  emit  the  "raw  material ;"  it  is  made  up  in  the  parts,  and  in 
each  after  its  proper  fashion.  The  real  process  of  formation  of  tissues 
is  altogether  extra-vascular,  even,  sometimes,  very  far  extra- vascular ; 
and  its  issue  depends  in  all  cases  chiefly,  and  in  some  entirely,  on  the 
affinities  (if  we  may  so  call  them)  between  the  part  to  be  nourished  and 
the  nutritive  fluid. 

The  third  condition  essential  to  the  healthy  nutrition  of  parts  is  a 
certain  influence  of  the  nervous  system.  It  may  be  held,  I  think,  that 
in  the  higher  vertebrata  some  nervous  force  is  habitually  exercised  in 
the  nutrition  of  all  the  parts  in  or  near  which  nerves  are  distributed ; 
and  that  it  is  exercised,  not  merely  in  afiecting  or  regulating  the  size 
of  the  bloodvessels  of  the  part,  but,  with  a  more  direct  agency,  as  being 
one  of  the  forces  that  concur  in  the  formative  process. 

Of  late  years,  a  current  of  opinion  has  run  against  the  belief  of  this  ; 
and,  of  those  who  admit  some  influence  of  the  nervous  system  upon  the 
nutrition  of  parts,  many  do  it,  as  it  were,  grudgingly  and  doubtfully. 
They  hold  that  at  most  the  influence  is  exercised  only  indirectly,  through 
the  power  which  the  nervous  system  has  of  affecting  the  size  of  the 
bloodvessels ;  or  that  the  nervous  system  influences  only  the  degree 
without  affecting  at  all  the  mode  of  nutrition  in  a  part. 

One  chief  argument  against  the  belief  that  the  nervous  force  has  a' 
direct  and  habitual  influence  in  the  nutritive  processes  is,  that  in  plants 
and  the  early  embryo,  and  in  the  lowest  animals,  in  which  no  nervous 
system  is  developed,  all  nutrition  goes  on  well  without  it.  But  this  is 
no  proof  that  in  animals  which  have  a  nervous  system,  nutrition  is 
independent  of  it :  rather,  even  if  we  had  no  positive  evidence,  we  might 

*  Professor  Owen  appears  to  have  been  the  first  to  suggest  the  existence  of  a  tubular 
system  in  tendon,  similar  to  the  lacunary  and  canalicular  system  in  bone  and  the  dentinal 
tubes  in  teeth. — Lect.  on  Comp.  Anat.  1846,  p.  29. 


HEALTHY    NUTRITION.  49 

assume  that  in  ascending  development,  as  one  system  after  another  is 
added  or  increased,  so  the  highest,  and  highest  of  all,  the  nervous 
system,  would  he  inserted  and  blended  in  a  more  and  more  intimate 
relation  with  all  the  rest.  This  would,  indeed,  he  only  according  to  the 
general  law,  that  the  interdependence  of  parts  augments  with  their 
development :  for  high  organization  consists  not  in  mere  multiplication 
or  diversity  of  independent  parts,  but  in  the  intimate  combination  of 
many  parts  in  mutual  maintenance. 

Another  argument  implies  that  the  nervous  force  can  manifest  itself 
in  nothing  but  impressions  on  the  mind  and  muscular  contraction-force. 
So  limited  a  view  of  the  convertibility  of  nervous  force  is  such  a  one 
as  the  older  electricians  would  have  held,  had  they  maintained  that  the 
only  possible  manifestations  of  electricity  were  the  attractions  and 
repulsions  of  light  bodies,  or  that  the  electric  force  could  never  be  made 
to  appear  in  the  form  of  magnetism,  of  chemical  action,  or  of  heat.  We 
are  too  much  shackled  with  these  narrow  dogmas  of  negation.  The 
evidence  of  the  correlation  and  mutual  convertibility  of  the  physical 
forces  might  lead  us  to  anticipate  a  like  variety  of  modes  of  manifesta- 
tion for  the  nervous  and  other  forces  exercised  in  the  living  body.* 
We  might  anticipate,  too,  that,  as  the  nervous  force  has  its  origin  in  the 
acts  of  nutrition  by  which  the  nerve-substance  is  formed,  so,  by  recipro- 
cal action,  its  exercise  might  affect  the  nutritive  acts.  As  (for  illustra- 
tion sake)  the  completed  blood  affects  all  the  processes  by  which  itself 
was  formed,  so,  we  might  suppose,  would  the  nervous  force  be  able  to 
affect  all  the  acts  of  which  itself  is  the  highest  product. 

But  we  need  not  be  content  with  these  probable  deductions  concern- 
ing the  direct  influence  of  the  nervous  force  on  the  nutritive  process. 
The  facts  bearing  on  the  question  seem  sufficient  for  the  proof,- 

A  first  class  of  them  are  such  as  show  the  influence  of  the  mind  upon 
nutrition.  Various  conditions  of  the  mind  acting  through  the  nervous 
system,  and  by  nervous  force,  variously  affect  the  formative  processes 
in  the  whole  body.  There  is  scarcely  an  organ  the  nutrition  of  which 
may  not  thus  be  affected  by  the  mind.  It  is  hardly  necessary  to  adduce 
examples  of  a  fact  so  often  illustrated ;  yet  I  may  mention  this  one : 
Mr.  Lawrence  removed,  several  years  ago,  a  fatty  tumor  from  a 
woman's  shoulder ;  and  when  all  was  healed  she  took  it  into  her  head 
that  it  was  a  cancer  and  would  return.  Accordingly,  when  by  accident 
I  saw  her  some  months  afterwards,  she  was  in  a  workhouse,  and  had  a 
large  and  firm  painful  tumor  in  her  breast,  which,  I  believe,  would  have 
been  cut  out,  but  that  its  nature  was  obscure,  and  her  general  health 
was  not  good.  Again,  some  months  afterwards,  she  became  my  patient 
at  the  Finsbury  Dispensary :  her  health  was  much  improved,  but  the 
hard  lump  in  her  breast  existed  still,  as  large  as  an  egg,  and  just  like 
a  portion  of  indurated  mammary  gland.     Having  heard  all  the  account 

*  See  Carpenter  on  the  Mutual   Relation  of  the  Vital  and  the  Physical  Forces,  Phil. 
Trans.,  1850,  and  General  Physiology,  p.  34. 


50  CONDITIONS    NECESSARY    TO 

of  it,  and  how  her  mind  constantly  dwelt  in  fear  of  cancer,  I  made  bold . 
to  assure  her,  by  all  that  was  certain,  that  the  cancer,  as  she  supposed 
it,  would  go  away ;  and  it  did  become  very  much  smaller  without  any 
help  from  medicine.  As  it  had  come  under  the  influence  of  fear,  so  it 
very  nearly  disappeared  under  that  of  confidence.  But  I  lost  sight  of 
her  before  the  removal  of  the  tumor  was  complete. 

The  other  classes  of  cases  are  those  in  which  the  influence  of  the 
nervous  system  alone,  independent  of  the  Mind,  is  shown.  Of  course, 
such  cases  can  only  be  drawn  from  those  of  abstraction  or  perversion  of 
the  nervous  influence ;  and  the  efiects  of  these  are  most  plainly  expressed 
in  the  nutrition  of  parts  exposed  to  external  agencies,  as  the  integu- 
ments generally,  the  extremities,  and  other  external  parts  ;  but  we  may 
fully  believe,  that  what  is  observed  in  these,  occurs  also,  in  correspond- 
ing measure,  in  more  deeply-sedted  parts. 

Now,  for  the  results  of  the  abstraction  or  diminution  of  nervous  force, 
I  cite  the  following  from  among  many  similar  facts :  In  the  Museum 
of  St.  Bartholomew's  (Ser.  9,  No.  9)  is  an  example  of  central  pene- 
trating ulceration  of  the  cornea,  in  consequence  of  destruction  of  the 
trunk  of  the  trigeminal  nerve,  by  the  pressure  of  a  tumor  near  the 
pons.*  The  whole  nutrition  of  the  corresponding  side  of  the  face  was 
impaired ;  the  patient  had  repeated  attacks  of  erysipelatous  inflamma- 
tion, bleeding  from  the  nose,  and,  at  length,  destructive  inflammation  of 
the  tunics  of  the  eye,  and  this  ulceration  of  the  cornea. 

In  the  College  Museum  (No.  2177)  is  the  hand  of  a  man,  whose  case 
is  related  by  Mr.  Swan,  the  donor  of  the  preparation.  The  median 
nerve,  where  it  passes  under  the  annular  ligament,  is  enlarged  with 
adhesion  to  all  the  adjacent  tissues,  and  induration  of  both  it  and  them. 
A  cord  had  been  drawn  very  tight  round  this  man's  wrist  seven  years 
before  the  amputation  of  the  arm.  At  this  time  it  is  probable  the 
median  and  other  nerves  suffered  injury ;  for  he  had  constant  pain  in 
the  hand  after  the  accident,  impairment  of  the  touch,  contraction  of  the 
fingers,  and  (which  bears  most  on  the  present  question)  constantly 
repeated  ulcerations  at  the  back  of  the  hand. 

Mr.  Hilton  has  told  me  this  case :  A  man  was  at  Guy's  Hospital, 
who,  in  consequence  of  a  fracture  at  the  lower  end  of  the  radius, 
repaired  by  an  excessive  quantity  of  new  bone,  suffered  compression  of 
the  median  nerve.  He  had  ulceration  of  the  thumb,  and  fore  and 
middle  fingers,  which  resisted  various  treatment,  and  was  cured  only  by 
so  binding  the  wrist  that  the  parts  on  the  palmar  aspect  being  relaxed, 
the  pressure  on  the  nerve  was  removed.  So  long  as  this  was  done,  the 
ulcers  became  and  remained  well ;  but  as  soon  as  the  man  was  allowed 
to  use  his  hand,  the  pressure  on  the  nerves  was  renewed,  and  the 
ulceration  of  the  parts  supplied  by  them  returned. 

Mr.  Traversf  mentions  a  case  in  which  a  man  had  paraplegia  after 

*  The  case  is  related  by  Mr.  Stanley  in  the  Medical  Gazette,  vol.  i,  531. 
t   Further  Inquiry  concerning  Constitutional  Irritation,  p.  436. 


HEALTHY    NUTEITION.  51 

fracture  of  the  lumbar  vertebrae.  He  fractured  at  the  same  time  his  hu- 
merus and  his  tibia.     The  former,  in  due  time,  united ;  the  latter  did  not. 

Mr.  De  Morgan*  has  related  a  similar  case.  A  man  fractured  his 
twelfth  dorsal  vertebra,  and  crushed  the  cord ;  dislocated  his  left 
humerus,  and  fractured  fourteen  ribs  and  his  ^left  ankle.  He  lived 
eighteen  days,  during  which  the  reparative  process  was  active  at  the 
injuries  above  the  damage  of  the  cord,  but  seemed  to  be  wholly  wanting 
at  those  below  it. 

Sir  B.  C.  Brodie  mentions  having  seen  mortification  of  the  ankle 
begin  within  twenty-four  hours  after  an  injury  of  the  spine. f 

It  would  be  easy  to  multiply  facts  of  this  kind,  without  adducing 
instances  of  experiments  on  lower  animals,  which,  though  they  be  cor- 
roborative, cannot  be  fairly  applied  here.  I  will  only  refer  in  general 
to  the  numerous  recorded  examples  of  the  little  power  which  paralyzed 
parts  have  of  resisting  the  influence  of  heat ;  of  the  sloughing  after 
injury  of  the  spinal  cord ;  of  the  slower  repair  and  reproduction  of  parts 
whose  nerves  are  paralyzed  or  divided ;  all  which  facts  alike  contribute 
to  prove  that  the  integrity  of  the  nervous  centres  and  trunks  which 
are  in  anatomical  relation  with  a  part,  is  essential  to  its  due  nutrition, 
or  to  its  capacity  of  maintaining  itself  against  the  influence  of  external 
forces,  which  capacity  is  itself  an  expression  of  the  formative  power. 

Lastly,  for  cases  illustrating  the  eff"ects  produced  in  nutrition  by 
disturbances  of  the  nervous  force,  I  must  refer  to  the  Lectures  on 
Inflammation.  At  present,  I  can  only  allude  to  the  cases  of  inflamma- 
tion of  the  conjunctiva  excited  by  stimulus  of  the  retina  ;  of  inflamma- 
tion of  the  testicle  in  consequence  of  mechanical  irritation  of  the 
urethra  ;  of  the  vascular  congestion  which  is  instantly  produced  around 
a  killed  or  intensely  irritated  part,  or  in  and  around  a  part  in  which 
paroxysms  of  neuralgia  are  felt;  of  the  inflammations  whose  range 
seems  to  be  determined  by  the  course  of  distribution  of  nerves,  as  in 
Herpes  Zona.|  In  all  these  cases  I  know  no  explanation  for  the  dis- 
turbance of  nutrition  except  that  it  is  the  consequence  of  the  nervous 
force  in  the  part  being  directly,  or  by  reflection,  disturbed. 

The  value  of  all  these  facts  is  strengthened  by  the  consideration  of 
the  manifold  and  distinct  influences  of  the  nervous  force  upon  secretion ; 
for  the  process  of  secretion  is  so  essentially  similar  to  that  of  nutrition, 
that  whatever  can  be  proved  of  the  method  of  one  might  be  inferred  for 
that  of  the  other.  And  I  think  the  proof  of  the  direct  influence  of  the 
nervous  force  upon  the  formative  process  would  be  thus  beyond  question, 
if  it  were  not  for  the  inconstancy  of  the  results  of  injury  of  the  spinal 
cord  and  nerves.     Even  in  the  warm-blooded  animals  the  division  of 

*  London  Medical  and  Surgical  Journal,  Jan.  4,  1834. 

t  Lectures  on  Pathology  and  Surgery,  p.  309. 

J  Some  curious  cases  have  been  recorded  by  Dr.  Charcot,  in  Brown-Sequard's  Journal 
(January,  1859J,  where  irritation  of  certain  of  the  nerves  of  the  limbs  was  followed  by 
eruptions  on  the  portions  of  skin  supplied  by  those  nerves. 


52  CONDITIONS    NECESSARY    TO 

the  cord  does  not  always  retard  the  healing  of  injuries  in  the  paralyzed 
limbs ;  sometimes  it  scarcely  affects  any  part  of  their  nutrition  ;  and 
even  in  man,  healing  may  be  effected  in  paralyzed  limbs  after  injuries, 
though  they  be  produced  by  such  trivial  causes  as  would  not  have  dis- 
turbed the  nutrition  of  sound  limbs.  I  remember  a  man  with  nearly 
complete  paraplegia  and  distorted  feet,  the  consequence  of  injuries  of 
the  spine,  in  whom  some  tendons  were  subcutaneously  divided,  and 
appeared  to  be  healing ;  but  a  bandage  being  applied  rather  tightly, 
sloughing  ensued  at  the  insteps,  on  which  the  chief  pressure  fell,  and 
extended  widely  and  deeply  to  the  ankle-joints.  Both  the  dorsal 
arteries  were  laid  open  when  the  sloughs  separated,  and  both  the  ankle- 
joints,  and  the  case  presented  a  most  striking  example  of  the.  defective 
self-maintenance  of  paralyzed  parts.  But  granulations  formed  after  the 
separation  of  the  sloughs,  and  the  healing  process  went  on  slowly,  but 
uninterruptedly,  till  all  was  covered  in  with  a  well-formed  scar.  In 
another  case,  a  girl,  with  softening  of  the  brain,  had  sloughs  on  nearly 
every  part  of  the  body  that  was  subject  to  even  slight  pressure :  for 
instance,  on  the  back  of  her  head  resting  on  the  pillow,  on  her  elbows 
and  heels  ;  and  yet,  while  several  of  these  sloughs  were  extending  with 
fearful  rapidity,  an  ulcer,  which  had  remained  after  the  separation  of  a 
slough  over  the  patella,  healed  perfectly. 

Such  cases  as  these  seem  incongruous  in  their  several  parts,  and 
irreconcilable  with  the  general  rules  which  I  previously  illustrated.  I 
cannot  attemjDt  to  explain  them ;  but  neither  can  I  think  that  they 
materially  invalidate  the  rule.* 

*  Much  of  what  seemed  to  be  inexphcable  in  the  variety  of  consequences  of  injury  done 
to  the  nervous  system,  is  explained  by  Brovsm-Sequard  (Journal  de  la  Physiologic,  Jan. 
1859).  He  has  shown  that  in  estimating  the  influence  of  the  nervous  system  on  nutrition, 
we  must  distinguish  between  the  effects  produced  by  irritation  of  the  spinal  cord  and  nerves, 
which  occasion  morbid  action  in  a  part,  and  those  due  to  simple  cessation  of  action  ;  as  when 
the  cord,  or  the  nerve  going  to  a  part,  is  divided.  Where  there  is  irritation  of  the  nervous 
system,  as  when  the  cord  is  pressed  upon  by  a  fractured  spine,  or  other  morbid  cause,  or  a 
nerve  is  compressed  by  a  tumor  or  inflammatory  adhesion,  then  ulceration  and  gangrene 
may  be  set  up  soon  after  the  occurrence  of  the  lesion.  On  the  other  hand,  when  there  is  a 
cessation  of  action  in  a  part,  due  to  the  withdrawal  of  the  nervous  influence,  as  in  section 
of  a  nerve,  then  a  slow  and  simple  atrophy  takes  place.  This  explanation,  however,  hardly 
appears  to  be  applicable  to  all  cases,  for  in  the  one  cited  above,  the  process  of  repair  fol- 
lowed that  of  rapid  sloughing,  without  any  apparent  change  in  the  state  of  the  nervous 
organs. 

All  that  can  be  said  against  the  participation  of  the  nerve-force  in  the  process  of  nutrition 
may  be  found  in  Virchow  (Cellular  Pathologic,  Lecture  14).  But  his  negatives,  numerous 
though  they  are.  are  not  sufficient  to  prevail  against  the  more  numerous  positive  experi- 
ments which  have  been  made  of  late  years.  Bernard,  Waller,  Brown-Sequard,  Budge, 
Schiff,  Wharton  Jones,  and  Lister,  have  proved  to  a  complete  demonstration  that  the  nervous 
system  exercises  a  most  important  influence  over  the  condition  of  the  bloodvessels  of  a  part. 
The  general  result  of  their  experiments  has  been  to  show  that  enlargement  of  the  blood- 
vessels, a  more  rapid  flow  of  blood,  increased  redness  and  temperature,  rapidly  follow  the 
division  of  the  nerves.  The  converse  of  the  above,  namely,  contraction  of  the  bloodvessels, 
pallor,  and  diminished  temperature,  occur,  when,  after  division,  galvanism  is  applied  to  the 
nerves  going  to  a  part.  Lister  (Phil.  Trans.  1858)  has  shown  that  the  controlling  power  is 
not  exercised  exclusively  by  any  single  part  of  the  nervous  axis,  but  that  the  function  is  ap- 


HEALTHY   NUTRITION.  53 

Let  me  add  further,  that  no  tissue  seems  to  be  wholly  exempt  from 
the  influence  of  the  nervous  force  on  its  nutrition.  In  the  cuticle  it  is 
manifest ;  and  for  its  influence  in  acting  even  through  a  considerable  dis- 
tance, I  may  mention  a  case,  which  is  also  in  near  relation  to  those  in 
which  the  hair  grows  quickly  gray,  in  mental  anguish.  A  lady,  who  is  sub- 
ject to  attacks  of  what  are  called  nervous  headaches,  always  finds  in  the 
morning  after  such  a  one,  that  some  patches  of  her  hair  are  white  as  if 
powdered  with  starch.  The  change  is  effected  in  a  night,  and  in  a  few 
days  after,  the  hairs  gradually  regain  their  dark  brownish  color. 

If,  now,  we  may  hold  this  influence  of  the  nervous  system  to  be 
proved^  we  may  consider  the  question,  through  what  class  of  nerves  is 
the  nutritive  process  influenced  ? 

Indirectly,  it  is  certain  that  the  motor  or  centrifugal  nerves  may  in- 
fluence it ;  for  when  these  are  paralyzed,  the  muscles  they  supply  will 
be  inactive,  and  atrophy  will  ensue,  first  in  these  muscles :  then  in  the 
bones  (if  a  limb  be  the  seat  of  the  paralysis),  for  the  bones,  in  their  nu- 
trition, observe  the  example  of  their  muscles :  and  finally,  the  want  of 
energy  in  the  circulation,  which  is  in  some  measure  dependent  on  mus- 
cular action,  will  bring  about  the  atrophy  of  the  other  tissues  of  the 
part.  Hence,  after  a  time,  the  evidences  of  paralysis  of  the  facial 
nerve  may  be  observed  in  nearly  all  the  tissues  of  the  face. 

But  the  effects  of  the  destruction  of  the  trigeminal  nerve,  while  the 
motor  nerves  of  the  parts  which  it  supplies  are  unimpaired,  prove  that 
a  more  direct  influence  is  exercised,  through  sensitive  or  sympathetic 
nerves.  The  olfactory,  optic,  third,  fourth,  sixth,  and  facial  nerves 
may  be  one  and  all  destroyed,  yet  no  disturbance  of  the  nutrition  of  the 
nose  or  eye  may  ensue.     After  destruction  of  the  facial,  indeed,  there 

parently  regulated  by  the  whole  length  of  the  cord,  and  the  posterior  part  of  the  brain.  His 
experiments  would  also  render  it  probable  that  there  is  in  addition,  a  co-ordinating  gan- 
glionic apparatus  in  the  part  itself,  which,  under  special  conditions  of  direct  irritation,  is 
capable  of  independent  action.  Of  great  value,  also,  in  their  relation  to  this  important  sub- 
ject, are  the  recent  observations  of  Mr.  Lister  (Op.  cit.  p.  627)  on  the  cutaneous  pigmentary 
system  of  the  frog.  He  points  out  that  the  pigment  is  contained  in  radiated  cells,  and  that 
the  light  or  dark  color  of  the  frog's  skin,  depends  upon  whether  the  pigment  is  concentrated 
in  the  centre  of  these  cells,  or  diffused  throughout  their  processes.  These  pigment  cells  are 
under  the  control  of  the  nervous  system  ;  for  when  the  nerves  going  to  a  part  are  divided,  a 
diffusion  of  the  pigment  and  a  dark  tint  of  the  skin,  comparable  to  the  arterial  relaxation, 
which  takes  place  from  the  same  cause,  are  produced.  Again,  when  the  nerves  of  a  part 
are  irritated,  concentration  of  the  pigment  and  pallor  of  the  skin,  comparable  to  the  contrac- 
tion of  the  muscular  fibres  of  the  arteries,  are  occasioned.  We  have,  therefore,  in  these  ex- 
periments, direct  evidence  of  the  influence  exercised  by  the  nervous  system  over  the  con- 
tents of  the  proper  cellular  elements  of  a  texture. 

But  this  influence  of  the  nervous  system  is  not  confined  to  the  action  which  it  exercises 
upon  the  contraction  of  the  walls  of  the  vessels,  or  the  movements  of  the  pigment  granules 
within  their  cells ;  for  various  experimenters,  more  especially  Ludwig  and  Bernard,  have 
pointed  out  that  by  stimulating  the  nerves  going  to  a  gland,  the  amount  of  secretion  formed 
in  it  may  be  greatly  increased.  The  glands  which  they  have  particularly  operated  on 
are  the  lachrymal  and  salivary.  In  these  cases  we  cannot  help  supposing  that  the  effect 
produced  is  due,  not  merely  to  the  influence  exercised  by  the  nerves  over  the  calibre  of  the 
vessels  of  the  gland,  but  to  their  action  on  the  proper  secreting  elements. 


64  CONDITIONS    NECESSARY   TO 

may  be  inflammation  of  the  eye  from  irritants  wtiicli  the  paralyzed  or- 
bicularis palpebrarum  cannot  shut  out  or  help  to  remove  ;  but  neither 
this  nor  any  other  injury  of  these  nerves  is  comparable  with  the  conse- 
quences of  the  destruction  of  the  trigeminal ;  consequences  which  in 
the  rabbit  are  manifest,  and  may  be  very  grave  within  a  day  of  the  de- 
struction of  the  nerve,  and  may  be  completely  destructive  of  the  eye 
within  three  days.* 

In  many  of  these  cases  it  is  difficult  to  say  whether  the  influence  on 
nutrition  is  exercised  through  sensitive  nerve-fibres  of  the  cerebro-spi- 
nal  system,  or  through  sympathetic  (ganglionic)  nerve-fibres  ;  and  I 
think  it  is  probable  that  it  may  be  exercised  through  either. 

On  the  one  side  we  have  the  fact  that  the  desti'uction  of  the  eye  en- 
sues more  quickly  after  division  of  the  trigeminal  nerve  in  front  of  the 
Gasserian  ganglion,  than  when  the  division  is  made  between  the  gan- 
glion and  the  brain.  This  may  imply  that  filaments  derived  from  the 
ganglion,  or  passing  through  it  from  the  sympathetic  nerve,  are  those 
throuD-h  which  the  influence  on  nutrition  is  exercised.  And  their  suffi- 
ciency  is  supported  by  the  fact  that  great  disturbance  in  the  nutrition 
of  the  eye  is  an  ordinary  consequence  of  the  extirpation  of  the  superior 
cervical  ganglion  of  the  sympathetic,  even  when  the  trigeminal  nerve  is 
unafi"ected.t 

But,  on  the  other  side,  we  have  the  facts  of  the  destruction  of  the 
eye,  when  the  trigeminal  nerve  is  spoiled  near  its  origin,  the  sympa- 

■^  Some  recent  experiments  by  Snellen  (De  invloed  der  Zenuwen  op  de  Ontsteking,  Ut- 
recht, 1857),  would  appear,  indeed,  to  show,  that  after  division  of  the  trigeminal  nerve,  de- 
struction of  the  eyeball  may  be,  for  a  time  at  least,  averted,  by  preventing  all  irritating 
agents  from  coming  in  contact  with  the  front  of  the  globe.  This  Snellen  effected  by  closing 
the  lids,  and  stitching  the  sensitive  ear  of  the  rabbit  he  operated  on  in  the  front  of  the  eye. 
Ten  days  after  the  operation  tile  eyeball  was  clear  and  normal.  The  conclusion  he  draws 
is  that  section  of  the  trigeminus  does  not  of  itself  produce  keratitis,  nor  affect  the  nutrition  of 
the  globe.  Schiff  (Physiologie,  part  i,  p.  387,  1859),  has  carefully  repeated  the  experiments 
of  Snellen,  and  finds  that  in  every  case,  after  section  of  the  nerve,  hypersemia  of  the  iris  and 
conjunctiva,  with  increased  secretion  of  conjunctival  mucus,  immediately  occurs.  The  opa- 
city of  the  cornea  was,  however,  although  never  completely  wanting,  yet  very  variable  in 
amount  and  position,  which  variation  appears  to  indicate  that  corneal  opacity  is  not  an  im- 
mediate and  necessary  consequence  of  neuroplastic  hyperemia.  It  is  only,  however,  when 
this  form  of  hypersemia  exists,  that  a  comparatively  slight  irritation  can  produce  inflamma- 
tion and  destruction  of  the  globe.  Whilst  the  above  experiments  show  that  section  of  a 
nerve,  involving  withdrawal  of  nervous  influence,  may  produce  but  little  change  in  the  mode 
of  nutrition  of  an  organ,  beyond  hypersemia  and  the  consequences  resulting  from  it,  other 
experiments  again  illustrate  the  very  serious  mischief  which  may  arise  if  a  nerve  be  irri- 
tated. Thus  Samuel  (Schmidt's  Jahrbuch,  1859,  No.  10,  p.  102),  by  passing  a  galvanic 
current  through  the  Gasserian  ganglion,  produced  immediate  vascularity  of  the  conjunctiva, 
an  abundant  flow  of  tears,  and  increased  sensibility  of  the  parts,  which  after  a  time  were 
followed  by  violent  inflammation,  with  opacity  of  the  cornea. 

f  There  is  reason  to  believe  that  the  experiments  of  Magendie,  on  which  physiologists 
base  the  statement,  that  destruction  of  the  eye  ensues  more  quickly  after  division  of  the 
ophthalmic  division  of  the  fifth,  than  when  the  division  is  made  between  the  ganglion  and 
the  brain,  are  either  erroneous,  or  have  been  misinterpreted.  For  Schiff  (Op.  cit.  p.  388), 
from  numerous  experiments,  has  convinced  himself  that,  in  relation  to  vascular  paralysis 
and  its  consequences,  there  are  no  recognizable  differences  produced  in  the  eye  when  the 
nerve  is  divided  in  front  of,  or  behind,  the  ganglion. 


HEALTHY    NUTRITION.  55 

thetic  nerve  being  sound  (as  in  the  case  by  Mr.  Stanley) ;  and  of  the 
defective  nutrition  in  consequence  of  injuries  of  the  spinal  cord,  when 
also  the  sympathetic  centres  are  uninjured ;  as  in  the  cases  by  Sir  B. 
C,  Brodie  and  Mr.  Travers.  For  this  view,  also,  is  the  occurrence  of 
general  atrophy  in  consequence  of  diseases  of  the  brain. 

Finally,  when  defective  nutrition  follows  injury  of  the  spinal  cord,  it 
appears  to  be,  directly,  due  to  the  injury  of  the  sensitive  rather  than 
the  motor  nerve-fibres.  Sloughing  of  the  bladder  and  other  parts  oc- 
curs, I  believe,  in  such  cases,  earlier  and  more  extensively  when  sensa- 
tion, than  when  motion  alone,  is  lost.  And  Mr.  Curling  has  recorded 
this  case  :*  Two  men  were,  at  nearly  the  same  time,  taken  to  the 
London  Hospital  with  injury  of  the  spine  ;  one  had  lost  only  the  power 
of  motion  in  the  lower  extremities ;  the  other  had  lost  both  motion  and 
sensation  ;  and  at  the  end  of  four  months  the  atrophy  of  the  lower  ex- 
tremities in  this  last  was  far  more  advanced  than  in  the  first. 

None  of  these  cases,  however,  enable  us  to  say  whether  the  influence 
on  nutrition  is  exercised  through  sensitive  fibres  of  the  cranio-spinal 
system  or  through  sympathetic  fibres  ;  nor  do  I  think  this  question  can 
be  yet  determined. 

The  last  condition  which  I  mentioned  as  essential  to  healthy  nutri- 
tion, is  a  healthy  state  of  the  part  to  be  nourished. 

This  is,  indeed,  involved  in  the  very  idea  of  the  assimilation  which  is 
accomplished  in  the  formative  process,  wherein  the  materials  are  sup- 
posed to  be  made  like  to  the  structures  among  which  they  are  deposited  ; 
for  unless  the  type  be  good,  the  antitype  cannot  be. 

In  a  part  which  was  originally  well  formed,  and  with  which  the  three 
conditions  of  nutrition  already  illustrated  have  been  always  present, 
this  fourth  condition  will  probably  be  never  wanting ;  for  the  part  will 
not  of  itself  deflect  from  the  normal  state.  But  when  any  part,  or  any 
constituent  of  the  blood,  has  been  injured  or  diseased,  its  unhealthy 
state  will  interfere  with  its  nutrition  long  after  the  immediate  eff"ects  of 
the  injury  or  disease  have  passed  away.  Just  as,  in  healthy  parts,  the 
formative  process  exactly  assimilates  the  new  materials  to  the  old,  so 
does  it  in  diseased  parts  :  the  new-formed  blood  and  tissues  take  the 
likeness  of  the  old  ones  in  all  their  peculiarities,  Avhether  normal  or  ab- 
normal ;  and  hence  the  healthy  state  of  the  part  to  be  nourished  may  be 
said  to  be  essential  to  the  healthy  process  of  nutrition. 

The  exactness  of  assimilation  accomplished  by  the  formative  process 
in  healthy  parts  has  been  already,  in  some  measure,  illustrated,  as  pre- 
serving through  life  certain  characteristic  difi'erences,  even  in  the  several 
parts  of  one  organ  ;  preserving,  also,  all  those  peculiarities  of  struc- 
ture and  of  action,  which  form  the  proper  features,  and  indicate  the 
temperament,  of  the  individual. 

*  Medico-Chir.  Trans,  vol.  xx,  p.  342. 


56  CONDITIONS    NECESSARY    TO 

In  these,  and  in  a  thousand  similar  instances,  the  precision  of  assimi- 
lation in  the  formative  process  is  perfect  and  absolute,  except  in  so  far 
as  it  admits  of  a  very  gradual  alteration  of  the  parts,  in  conformity 
with  the  law  of  change  in  advancing  years. 

Nor  is  there  less  of  exactness  in  the  assimilation  of  which  a  part  that 
has  been  diseased  is  the  seat.  For,  after  any  injury  or  disease,  by 
which  the  structure  of  a  part  is  impaired,  we  find  the  altered  struc- 
ture,— whether  an  induration,  a  cicatrix,  or  any  other, — as  it  were, 
perpetuated  by  assimilation.  It  is  not  that  an  unhealthy  process  con- 
tinues :  the  result  is  due  to  the  process  of  exact  assimilation  operating 
in  a  part  of  which  the  structure  has  been  changed  :  the  same  process 
which  once  preserved  the  fiealthy  state,  maintains  now  the  diseased  one. 
Thus,  a  scar  or  a  diseased  spot  may  grow  and  assimilate  as  its  healthy 
neighbors  do.  The  scar  of  the  child,  when  once  completely  formed, 
commonly  grows  as  the  body  does,  at  the  same  rate,  and  according  to 
the  same  general  rule  ;  so  that  a  scar  which  the  child  might  have. said 
was  as  long  as  his  own  fore-finger,  will  still  be  as  long  as  his  fore- 
finger when  he  grows  to  be  a  man. 

Yet,  though  this  increase  and  persistence  of  the  morbid  structure  be 
the  general  and  larger  rule,  another  within  it  is  to  be  remembered  ; 
namely,  that  in  these  structures  there  is  usually  (especially  in  youth)  a 
tendency  towardis  the  healthy  state. 

Hence,  cicatrices,  after  long  endurance,  and  even  much  increase,  may, 
as  it  is  said,  wear  out ;  and  thickenings  and  indurations  of  the  parts 
may  give  way,  and  all  become  again  pliant  and  elastic. 

The  maintenance  of  morbid  structures  is  so  familiar  a  fact,  that  not 
only  its  wonder,  but  its  significance,  seem  to  be  too  much  overlooked. 
What  we  see  in  scars  and  thickenings  of  parts  appears  to  be  only  an  ex- 
ample of  a  very  large  class  of  cases  ;  for  this  exactness  by  which  the  for- 
mative process  in  a  part  maintains  the  change  once  produced  by  disease, 
offers  a  reasonable  explanation  of  the  fact  that  certain  diseases  usually 
occur  only  once  in  the  same  body.  The  poison  of  small-pox,  or  of  scar- 
let fever,  being,  for  example,  once  inserted,  soon,  by  multiplication  or 
otherwise,  affects  the  whole  of  the  blood  ;  alters  its  whole  composition  ; 
the  disease,  in  a  definite  form  and  order,  pursues  its  course ;  and, 
finally,  the  blood  recovers,  to  all  appearance,  its  former  state.  Yet  it 
is  not  as  it  was  :  for  now  the  same  material,  the  same  variolous  poison, 
will  not  produce  the  same  efi"ect  upon  it ;  and  the  alteration  thus  made 
in  the  blood  or  the  tissues  is  made  once  for  all :  for,  commonly,  through 
all  after-life  the  formative  process  assimilates,  and  never  deviates  from 
the  altered  type,  but  reproduces  materials  exactly  like  those  altered  by 
the  disease;  the  new  ones,  therefore,  like  the  old,  are  incapable  of  al- 
teration by  the  same  poison,  and  the  individual  is  safe  from  the  danger 
of  infection. 

So  it  must  be,  I  think,  with  all  diseases  which,  as  a  general  rule,  at- 
tack the  body  only  once.     The  most  remarkable  instance,  perhaps,  is 


HEALTHY    NUTRITION.  57 

that  of  the  vaccine  virus.  Inserted  once  in  almost  infinitely  small 
quantity  :  yet,  by  multiplying  itself,  or  otherwise,  aifecting  all  the  blood, 
it  may  alter  it  once  for  all.  For,  unsearchable  as  the  changes  it  eifects 
may  be,  inconceivably  minute  as  the  diiference  must  be  between  the 
blood  before,  and  the  blood  after,  vaccination  ;  yet,  in  some  instances, 
that  difierence  is  perpetuated  ;  in  nearly  all  it  is  long  retained  ;  by  as- 
similation, the  altered  model  is  precisely  imitated,  and  all  the  blood 
thereafter  formed  is  insusceptible  of  the  action  of  the  vaccine  matter. 

In  another  set  of  diseases  we  see  an  opposite,  yet  not  a  contradic- 
tory result.  In  these,  a  part  once  diseased  is,  more  than  it  was  before, 
liable  to  be  affected  by  the  same  disease  ;  and  the  liability  to  recurrence 
of  the  disease  becomes  greater  every  time,  although  in  the  intervals  be- 
tween the  successive  attacks  the  part  may  have  appeared  quite  healthy. 
Such  is  the  case  with  gout,  with  common  inflammation  of  a  part,  as  the 
eye,  and  many  others,  in  which  people  become,  as  they  say,  every  year 
more  and  more  subject  to  the  disease. 

I  do  not  pretend  to  determine  the  essential  difference  between  the 
two  classes  of  disease  in  these  respects,  in  which  they  are  antipodal ; 
but  in  reference  to  the  physiology  of  the  formative  process,  they  both 
prove  the  same  thing,  viz.,  that  an  alteration  once  produced  in  a  tissue, 
whether  by  external  influence,  or  by  morbid  material  in  the  blood,  is 
likely  to  be  perpetuated  by  the  exactness  of  assimilation  observed  in 
the  formative  process,  i.  e.  by  the  constant  reproduction  of  parts  in 
every  respect  precisely  like  their  immediate  predecessors. 

But  it  will  be  said,  the  rule  fails  in  every  case  (and  they  are  not  rare) 
in  which  a  disease  that  usually  occurs  but  once  in  the  same  body,  oc- 
curs twice  or  more  ;  and  in  every  case  of  the  second  class  in  which  lia- 
bility to  disease  is  overcome.  Nay,  but  these  are  examples  of  the  ope- 
ration of  that  inner,  yet  not  less  certain,  law, — that  after  a  part  has 
been  changed  by  disease,  it  tends,  naturally,  to  regain  a  perfect  state. 
Most  often  the  complete  return  is  not  effected  ;  but  sometimes  it  is,  and 
the  part,  at  length,  becomes  what  it  would  have  been  if  disease  had 
never  changed  it. 

I  will  here  refer  again  to  what  was  said  in  the  first  lecture  concern- 
ing the  blood's  own  assimilative  power.  After  the  vaccine  and  other 
infectious  or  inoculable  diseases,  it  is,  most  probably,  not  the  tissues 
alone,  but  the  blood  as  much  or  much  more  than  they,  in  which  the 
altered  state  is  maintained ;  and  in  many  cases  it  would  seem  that, 
whatever  materials  are  added  to  the  blood,  the  stamp  once  impressed 
by  one  of  these  specific  diseases  is  retained ;  the  blood,  by  its  own  for- 
mative power,  exactly  assimilating  to  itself,  its  altered  self,  the  mate- 
rials derived  from  the  food. 

And  this,  surely,  must  be  the  explanation  of  many  of  the  most  in- 
veterate diseases ;  that  they  persist  because  of  the  assimilative  forma- 
tion of  the  blood.  Syphilis,  lepra,  eczema,  gout,  and  many  more, 
seem  thus  to  be  perpetuated :  in  some  form  or  other,  and  in  varying 

5 


58         CONDITIONS    NECESSARY    TO    HEALTHY    NUTRITION. 

quantity,  "wlietlier  it  manifests  itself  externally  or  not,  the  material  they 
depend  on  is  still  in  the  blood  ;  because  the  blood  constantly  makes  it 
afresh  out  of  the  materials  that  are  added  to  it,  let  those  materials  be 
almost  what  they  may.  The  tissues  once  aJBfected  may  (and  often  do), 
in  these  cases  recover ;  they  may  have  gained  their  right  or  perfect 
composition ;  but  the  blood,  by  assimilation,  still  retains  its  taint, 
though  it  may  have  in  it  not  one  of  the  particles  on  -which  the  taint 
first  passed  ;  and  hence,  after  many  years  of  seeming  health,  the  dis- 
ease may  break  out  again  from  the  blood,  and  affect  a  part  which  was 
never  before  diseased.  And  this  appears  to  be  the  natural  course  of 
these  diseases,  unless  the  morbid  material  be  (as  we  may  suppose),  de- 
composed by  some  specific  ;  or  be  excreted  in  the  gradual  tendency 
of  the  blood  (like  the  tissues)  to  regain  a  normal  state  ;  or  finally,  be, 
if  I  may  so  speak,  starved  by  the  abstraction  from  the  food  of  all  such 
things  as  it  can  possibly  be  made  from.* 

In  all  these  things,  as  in  the  phenomena  of  symmetrical  disease,  we 
have  proofs  of  the  surpassing  precision  of  the  formative  process  ;  a  pre- 
cision so  exact  that,  as  we  may  say,  a  mark  once  made  upon  a  particle 
of  blood  or  tissue,  is  not  for  years  efiaced  from  its  successors.  And 
this  seems  to  be  a  truth  of  widest  application ;  and  I  can  hardly  doubt 
that  herein  is  the  solution  of  what  has  been  made  a  hindrance  to  the 
reception  of  the  whole  truth  concerning  the  connection  of  an  immaterial 
Mind  with  the  brain.  When  the  brain  is  said  to  be  essential,  as  the 
organ  or  instrument  of  the  Mind  in  its  relations  with  the  external 
world,  not  only  to  the  perception  of  sensations,  but  to  the  subsequent 
intellectual  acts,  and  especially  to  the  memory  of  things  which  have 
been  the  objects  of  sense — it  is  asked,  how  can  the  brain  be  the  organ 
of  memory  when  you  suppose  its  substance  to  be  ever  changing  ?  or 
how  is  it  that  your  assumed  nutritive  change  of  all  the  particles  of  the 
brain  is  not  as  destructive  of  all  memory  and  knowledge  of  sensuous 
things  as  the  sudden  destruction  by  some  great  injury  is  ?  The  answer 
is,  because  .of  the  exactness  of  assimilation  accomplished  in  the  forma- 
tive process  :  the  effect  once  produced  by  an  impression  upon  the  brain, 
whether  in  perception  or  in  intellectual  act,  is  fixed  and  there  retained ; 
because  the  part,  be  it  what  it  may,  which  has  been  thereby  changed, 
is  exactly  represented  in  the  part  which,  in  the  course  of  nutrition, 
succeeds  to  it.  Thus,  in  the  recollection  of  sensuous  things,  the  Mind 
refers  to  a  brain,  in  which  are  retained  the  efiects,  or  rather,  the  like- 

*  The  progress  of  the  vaccine  or  variolous  infection  of  the  blood  shows  ns  that  a  permanent 
morbid  condition  of  that  fluid  is  established  by  the  action  of  these  specific  poisons  iipon  it. 
And  although  this  condition  may,  so  far  at  least  as  it  protects  the  individual  from  any  further 
attack  of  the  same  disease,  be  regarded  as  exercising  a  beneficial  influence  upon  the  economy, 
yet  it  is  not  the  less  to  be  looked  upon  as  a  morbid  state.  In  forming  an  estimate  of  the  per- 
sistent changes  produced  in  the  blood  by  these  and  similar  infectious  diseases,  v/e  must  not 
lose  sight  of  the  influence  which  the  tissues,  themselves  altered  by  the  inoculation,  exercise 
upon  the  blood.  They  will  necessarily  react  upon  it,  so  as  to  assist  materially  in  preserving 
a  permanent  morbid,  though  beneficial  condition. 


THE    FOEMATIVE    PROCESS.  59 

nesses  of  changes  that  past  impressions  and  intellectual  acts  had  made. 
As,  in  some  way  passing  far  our  knowledge,  the  Mind  perceived,  and 
took  cognizance  of  the  change  made  by  the  first  impression  of  an  ob- 
ject, acting  through  the  sense  organs  on  the  brain  ;  so  afterwards  it 
perceives  and  recognizes  the  likeness  of  that  change  in  the  parts  in- 
serted in  the  process  of  nutrition. 

Yet  here  also  the  tendency  to  revert  to  the  former  condition  or  to 
change  with  advancing  years  may  interfere.  The  impress  may  be 
gradually  lost  or  superseded,  and  the  Mind  in  its  own  immortal  nature 
unchanged,  and  immutable  by  anything  of  earth,  no  longer  finds  in  the 
brain  the  traces  of  the  past. 


LECTUEE  III. 

THE  FORMATIVE  PROCESS  :    GROWTH, 

Having  now  considered  the  sources  of  the  impairment  to  which  the 
completely  formed  blood  and  tissues  are  prone,  and  the  chief  conditions 
necessary  for  the  perfection  of  the  formative  process,  by  which,  not- 
withstanding this  impairment,  they  are  maintained  almost  unchanged, 
I  propose  to  speak  of  the  process  itself. 

You  may  remember  that  I  referred  the  impairment,  or  wear  and  tear, 
of  the  body  to  two  principal  sources — namely,  the  deterioration  which 
every  part  sufi"ers  in  the  exercise  of  its  function  ;  and  the  natural  de- 
generation or  death  to  which  every  part  is  subject  after  a  certain  pe- 
riod of  existence,  independently  of  the  death  or  degeneration  of  the 
whole  body,  and  in  some  measure,  independently  of  the  exercise  of 
function. 

The  first  question,  therefore,  in  the  consideration  of  the  nutritive 
process,  may  be, — what  becomes  of  the  old  particle,  the  one  for  the  re- 
placement of  which  the  process  of  formation  is  required  ?  In  answer, 
we  must,  probably,  draw  a  distinction,  though  we  can  hardly  define  it, 
between  the  parts  which  die,  and  those  which  only  degenerate,  when 
they  have  finished  their  course.  Those  which  die  are  cast  out  entire  : 
those  which  degenerate  are  disintegrated  or  dissolved,  and  absorbed. 
We  seem  to  have  a  good  example  of  this  difi"erence  in  the  fangs  of  the 
two  sets  of  teeth.  Those  of  the  deciduous  ones  degenerate,  are  trans- 
formed so  as  to  become  soluble  and  are  absorbed  ;  those  of  what  are 
called  permanent — more  properly  those  of  teeth  which  are  not  to  be 
succeeded  by  others,  die,  and  are  cast  out  entire.  And  we  may  proba- 
bly hold  it  as  generally  true,  that,  as  Mr.  Hunter  was  aware,  living  parts 
alone  are  absorbed  in  the  tissues ;  dead  parts,  it  is  most  probable,  how- 
ever small,  are  usually  separated  and  cast  out ;  and,  as  the  phenomena 


60  THE    FORMATIVE    PROCESS. 

of  necrosis  show,  this  must  be  accomplished,  not  by  the  absorption  of 
the  dead  parts  themselves,  or  their  borders,  but  by  the  absorption  or 
retirement  of  the  adjacent  borders  or  surfaces  of  the  living  parts. 

External,  merely  integumental,  parts  appear  thus  to  die  and  to  be 
cast  out  entire  from  the  body  ;  but  we  have  no  certain  knowledge  of 
the  changes  they  may  undergo  before  they  die.  And  with  regard  to 
the  changes  which  take  place  in  the  degeneration  that  precedes  absorp- 
tion of  the  old  particles,  we  have  again  but  little  knowledge.  Chemis- 
try has,  indeed,  revealed  much  concerning  the  final  disposal  of  the  old 
materials  ;  finding  their  elements  in  the  excretions  ;  and  proving  that 
the  process  is  one  of  descent  towards  simplicity  of  organic  chemical 
composition  ;  one  of  approximation  towards  inorganic  character  ;  and, 
perhaps  always,  one  accomplished  by  the  agency  of  oxygen.  It  has, 
also,  we  may  safely  believe,  found  in  the  muscles  some  of  the  substances 
into  which  the  natural  constituents  of  the  tissues  are  transformed,  be- 
fore they  assume  the  composition  in  which  they  are  finally  excreted. 
Kreatine  and  kreatinine  are,  most  probably,  examples  of  such  transi- 
tional compounds,  intermediate  between  some  of  the  proper  constituents 
of  muscle,  and  urea  or  uric  acid.  And  I  think  that  the  frequency  with 
which  fatty  matter  is  found  in  degenerate  parts  is  an  indication  that  it 
is  a  usual  product  of  similar  transformation  preparatory  to  absorp- 
tion, and  to  the  more  complete  combination  with  oxygen  in  the  forma- 
tion of  carbonic  acid  and  water  for  excretion.  However,  while  we  have 
so  little  knowledge  of  these  intermediate  or  transitional  substances,  we 
can  only  hold  it  as  generally  probable,  that  the  components  of  the  de- 
generate and  out-worn  tissues  pass  through  a  series  of  chemical  trans- 
formations, which  begin  in  their  natural  degeneration  before  absorp- 
tion, and  are  continued  during  and  after  absorption  till  they  are  com- 
pleted by  the  oxidation  in  the  blood  which  brings  the  materials  to  the 
state  appropriate  for  excretion. 

With  regard  to  the  formative  portion  of  the  process — that  by  which 
the  old  particle,  however  disposed  of,  is  to  be  replaced — it  is  in  many 
cases  a  process  of  development ;  a  renewal,  for  each  particle,  of  the 
process  which  was  in  nearly  simultaneous  operation  for  the  whole  mass 
in  the  original  development  of  the  tissue.  There  can  be  little  doubt 
that  such  is  the  case  in  the  hair,  the  teeth,  the  epidermis,  and  all  the 
tissues  which,  from  being  situated  on  a  free  surface,  we  can  watch ;  in 
all  these  the  process  of  repair  or  replacement  is  efi'ected  through  the 
development  of  new  parts.  With  regard  to  the  more  internal  parts,  as 
the  muscles,  their  position  prevents  us  from  obtaining  so  satisfactory  a 
view  of  the  nature  of  the  formative  process  which  goes  on  in  them.  It 
is  probable,  however,  that  there  is  not  such  a  bodily  replacement  as 
in  the  structures  more  superficially  placed,  but  that  the  nutritive 
changes  partake  more  of  the  molecular  character,  one  particle  being 
replaced  by  another,  whilst,  as  it  were,  the  original  skeleton,  or  frame- 
work, of  the  texture,  is  preserved.     In  all  the  parts,  I  think,  which  are 


THE    FORMATIVE    PROCESS.  .    61 

the  seats  of  active  nutrition,  nuclei  or  cytoblasts  exist.  These  nuclei 
(such  as  are  seen  so  abundantly  in  strong,  active  muscles)  are  not  the 
loitering  impotent  remnants  of  the  embryonic  tissue,  but  apparatus  of 
power  for  new  formation.  Their  abundance  is,  I  think,  directly  pro- 
portionate to  the  activity  of  growth.  They  are  always  abundant  in  the 
foetal  tissues,  and  those  of  the  young  animal ;  so  they  are  in  many  quickly 
growing  tissues ;  and  they  are  more  plentiful  in  the  muscles  and  the  brain 
than,  so  far  as  I  know,  any  other  non-secreting  tissue  of  the  adult. 
And  I  think  I  may  add  that  their  disappearance  from  a  part  in  which 
they  usually  exist  is  a  sure  accompaniment  and  sign  of  degeneration. 

A  subject  of  very  interesting  inquiry  is  involved  in  the  consideration 
of  the  way  in  which  parts  repeat  themselves  in  their  nutrition,  so  that 
the  structure  which  succeeds  is  constructed  after  the  plan  of  that  which 
preceded  it. 

Take  the  case  of  the  blood.  The  new  blood-corpuscles  that  are 
being  constantly  formed  for  the  renovation  of  the  blood,  are  not  de- 
veloped from  germs  given  off  from  the  old  ones  ;  neither  are  they  formed 
by  any  assimilative  force  exercised  by  the  old  ones.  By  watching  the 
stages  of  their  construction  we  may  see  that  the  development  of  each 
is  an  independent  repetition  of  the  process  by  which  the  first  were 
formed.  And  so  with  the  successive  developments  of  ova  and  epithelial 
cells,  and  many  others  ;  each  is  developed  independently  of  the  rest, 
and  each  repeats  the  changes  through  which  its  predecessors  passed. 

Let  it  then  be  observed  that  each  new  elementary  structure  is  made 
in  successive  stages,  like  what  the  old  one  was,  not  like  what  it  is  ;  as 
we  see  in  the  young  hair  following  the  course  of  the  old  one,  or  as  the 
child  is  made  like,  not  what  his  father  is  now,  but  what  he  was  at  his 
age.     The  new  particle  is,  therefore,  not  made  after  a  present  model. 

If,  now,  we  turn  from  the  consideration  of  the  method  of  the  forma- 
tive process  in  the  maintenance  of  the  tissues,  and  from  that  of  the  condi- 
tions under  which  it  is  exercised,  to  inquire  into  the  nature  of  the  forces 
which  actuate  it ;  if  we  try  to  answer  why  any  structure  just  new-formed 
has  assumed  nearly  the  same  form  as  the  old  structure  had  which  it 
replaces ;  we  may  find  suggestions  for  an  answer  in  the  facts  last  men- 
tioned. Among  these  facts  we  find  (1),  as  detailed  in  p.  55,  that  a 
structure  already  formed  exercises  a  certain  assimilative  influence  on 
organic  materials  brought  into  contact  or  near  proximity  with  it ;  and 
(2),  that  in  many  cases,  as  cited  above,  and  yet  more  clearly  in  in- 
stances of  repair  and  reproduction  of  injured  and  lost  parts,  the  re- 
placing structures  are  formed  entirely  anew,  and  independently  of  this 
influence.  In  these  cases  no  model  structure  is  present,  to  which  the 
new-forming  one  may  be  assimilated  ;  the  new  structure  seems  as  if  its 
own  inherent  properties  had  determined  the  form  that  it  should  take. 

Resting  on  the  first  class  of  facts,  it  seems  to  some  a  sufiicient  expla- 
nation of  the  process  of  maintenance  to  say,  that  each  structure  in  the 
body  has  the  power  of  taking  from   the  blood,  by  a  kind  of  elective 


62  THE    FORMATIVE    PROCESS. 

affinity,  certain  appropriate  materials,  and  of  so  influencing  them  that 
they  assimilate  themselves  to  it ;  i.  e.  that  they  adopt  or  receive  its 
form  and  properties,  and  incorporate  themselves  with  it. 

Now,  without  doubt,  the  existence  of  such  a  selective  power  is  justly 
assumed,  and  we  may,  by  reference  to  it,  express  correctly  a  part  of 
the  processes  by  which  the  maintenance  of  the  body  is  accomplished. 
Still  it  is,  I  think,  clear  that  it  is  not  sufficient  for  the  maintenance  of 
the  body  in  its  perfection ;  for,  in  the  explanation  of  all  the  facts  of 
the  second  class  cited  above,  a  theory  of  maintenance  of  the  tissues  by 
assimilation  is  inapplicable — not  merely  insufficient,  but  inapplicable ; 
for  a  postulate  of  this  theory  is  the  existence  of  a  present  model  or 
germ  for  the  construction  of  the  forming  part ;  and  in  all  these  cases 
no  such  germ  or  model  can  be  found.  Therefore,  finding  in  these  cases 
that  the  formative  process  is  accomplished  in  the  maintenance  of  certain 
parts,  without  assimilation,  we  may  assume,  I  think,  that  even  when 
this  condition  is  present,  it  is  only  as  an  auxiliary  of  some  more  con- 
stant and  sufficient  force. 

Of  this  force,  by  whatever  name  we  designate  it,  whether  as  the  for- 
mative, or  the  plastic,  or  more  explicitly,  as  the  force  by  which  or- 
ganic matter,  in  appropriate  conditions,  is  shaped  and  arranged  into 
organic  structure ;  of  this  force,  and  of  those  that  co-operate  with  it, 
we  can,  I  think,  only  apprehend  that  they  are,  in  the  completed  organ- 
ism, the  same  with  those  which  actuated  the  formation  of  the  original 
tissues  in  the  development  of  the  germ,  and  of  the  embryo.  As  we  have 
seen  that  the  new  formation  of  elemental  structures  in  the  maintenance 
of  tissues  is  a  repetition  of  the  process  observed  in  their  first  develop- 
ment, so  we  may  assume  that  the  forces  operative  are  the  same  in  both 
processes.* 

Thus  then,  for  explanation  of  the  maintenance  of  tissues  by  the  con- 
stant formation  of  nearly  similar  elemental  structures,  we  are  referred 
back  to  the  history  of  their  first  formation  ;  and  we  might  be  content 
to  rest  in  the  belief  that  the  mystery  of  the  development  of  a  germ  is 
wholly  inscrutable.  We  can  discern  in  its  method  only  this  :  that  the 
materials  of  which  the  impregnated  germ  first  consists,  and  all  that  it 

*  Concerning  the  very  nature  of  such  forces,  and  their  correlations,  I  must  refer  to  the 
admirable  essays  of  Mr.  Grove  (The  Correlation  of  Physical  Forces),  and  Dr.  Carpenter  (On 
the  Mutual  Relations  of  the  Vital  and  the  Physical  Forces).  "  In  speaking  oi  forces  as  pos- 
sessing an  absolute  existence,  it  is  not  intended,"  says  Dr.  Carpenter,  "  on  the  one  hand,  to 
imply  that  they  are  anything  else  than  '  affections  of  matter ;'  nor,  on  the  other,  to  regard 
them  in  any  other  light  than  as  the  direct  operation  of  the  Primal  All-sustaining  Cause. 
We  can  form  no  conception  of  matter  excei^t  as  ^possessing properties  vv^hich,  when  in  action, 
give  rise  \o  powers  or  forces  ;  whilst,  on  the  other  hand,  we  cannot  think  of  forces,  except  as 
operating  through  some  form  of  matter,  of  whose  properties  they  are  the  manifestation.  The 
existence  of  matter,  and  the  action  of  the  forces  to  which  the  material  phenomena  (whether 
physical  or  vital)  are  attributable,  are  alike  the  expressions  of  the  Divine  Will ;  and  our  aim 
must  be  limited  to  the  discovery  of  the  plan,  according  to  which  it  has  pleased  the  Creator 
to  develop  and  maintain  the  existing  condition  of  the  universe  we  inhabit." — General  Phy- 
siology^ p.  36. 


THE    FORMATIVE    PROCESS.  63 

appropriates,  are  developed  according  to  the  same  metliod  as  was  ob- 
served in  its  progenitors,  so  that  at  every  stage  it  is  like  what  they  were 
at  the  same  stage.  It  is  in  conformity  with  the  same  law  of  formation 
according  to  the  example  of  progenitors,  that  when  the  general  develop- 
ment of  the  body  is  completed,  each  of  its  parts  is  still  maintained  or 
gradually  changed.  In  each  period  of  life,  the  offspring  resembles  the 
parents  at  the  corresponding  periofls  of  their  life ;  and,  especially,  in 
those  degenerative  changes  which  ensue  in  old  age,  we  can  discern  no 
other  method,  or  law,  than  still  the  same  :  that  the  parental  form,  and 
properties,  and  life,  are  imitated  or  reproduced  in  the  offspring. 

Now,  can  we  trace  anything  further  back  than  this  fact  ?  Probably 
not ;  but  we  may  express  it  in  other  terms,  which  may  be  more  con- 
veniently used  in  our  further  inquiries,  by  saying  that  each  germ  de- 
rives from  its  parents  such  material  properties  that,  being  placed  in 
the  conditions  necessary  for  the  operation  of  the  formative  and  other 
vital  forces,  it  will  imitate  in  all  the  phases  of  the  life  of  each  of  its 
parts,  the  changes  through  which  the  corresponding  parts  passed  in  the 
parents.  It  is  convenient,  and  probably  right,  while  we  assume  the 
operation  of  a  formative  force,  still  to  refer  the  method  of  its  peculiar 
manifestations  to  the  material  properties  of  the  substances  in  which  it 
acts.  In  the  case  before  us,  we  may  accordingly  assume,  that  peculiar 
and  typical  properties  are  transmitted  from  its  parents  to  the  mate- 
rials of  each  impregnated  germ  ;  that  these  determine,  under  the  ope- 
ration of  the  formative  force,  the  construction  of  corresponding  pecu- 
liar, and  typical  forms  ;  that  they  are  also  communicated  to  whatever 
materials  capable  of  organization  are  brought  within  the  sphere  of  the 
developing  germ,  so  that  these  also  determine  the  same,  or  some  defi- 
nitely related,  method  of  construction  ;  and  that  thenceforward, 
throughout  life,  by  similar  communication  or  induction  of  specific  pro- 
perties in  the  forming  blood  or  other  nutritive  fluid,  the  same  method 
of  formation  is  maintained  in  all  the  tissues. 

Unless  we  thus  assume  a  dependence  of  form  upon  composition,  of 
organic  structure  upon  organic  constitution,  I  think  we  cannot  under- 
stand, or  even  clearly  speak  of,  many  of  the  deflections  from  the  nor- 
mal formative  process  which  are  due  to  injury  or  disease  :  deflections 
which,  as  we  have  seen,  are  maintained  in  the  blood  and  tissues,  and 
the  tendency  to  which  is,  in  hereditary  diseases,  transmitted  from  pa- 
rent to  offspring  with  the  other  properties  of  the  germ. 

The  sum,  then,  of  the  hypothesis  concerning  the  formative  processes 
in  the  maintenance  of  the  tissues  is  as  follows :  It  is  assumed,  first, 
that  a  certain  vital  formative,  or  plastic,  or  constructing  force,  is  in 
constant  operation  ;  2dly,  that  the  forms  assumed,  under  its  influence, 
depend  primarily,  and  in  greatest  measure,  on  the  specific  composition 
and  other  properties  of  the  organizable  materials  taken  from  the  blood  ; 
and,  3dly,  that  these  properties,  transmitted  in  the  first  instance  from 
the  parent  to  the  germ,  are  thenceforward  communicated  to  the  nutri- 


64  GROWTH. 

tive  materials,  subject,  however,  to  certain  progressive  changes  cor- 
responding to  the  development  and  degenerations  of  the  several  tis- 
sues.* 

It  is  assumed  further  that  the  taking  of  materials  from  the  blood,  by 
each  part  for  its  own  maintenance,  depends,  as  to  quality,  on  certain 
definite  relations,  or  "organic  affinities"  between  the  blood  and  the 
part;  and  as  to  quantity,  on  the  waste  of  the  part.  As  to  the  influ- 
ence of  an  assimilative  force,  exercised  by  the  tissues  already  formed, 
upon  the  nutritive  materials  placed  in  them,  it  is  probable  that  this  is 
not  a  plastic  or  constructive  force,  but  chiefly  such  a  one  as,  like  the 
assumed  catalytic  force,  or  that  of  a  ferment,  afi"ects  first  the  composi- 
tion of  the  materials  not  yet  organized,  and  thus  indirectly,  aflects  the 
form  that  they  assume  in  organizing. 

I  fear  I  may  have  seemed  to  have  engaTged  in  a  very  useless  discus- 
sion, and  to  have  been  talking  of  words  more  than  of  things ;  but  the 
charge  will  not  be  made  by  one  who  knows  the  utility  of  being  clear  in 
the  expressions  used  for  the  groundwork  of  teaching  ;  or  who  will  con- 
sider the  importance  in  pathology  of  the  principle  that  specific  organic 
structures  correspond  with,  and  are  determined  by,  specific  organic 
compositions. 

I  propose  now  to  consider,  but  as  yet  only  generally,  the  second  me- 
thod of  the  formative  process.  Growth,  in  health  and  in  disease. 

It  consists  in  the  increase  of  a  part,  or  of  the  whole  body,  by  addi- 
tion of  new  material  like  that  already  existing.  The  essential  charac- 
ters of  each  organ  or  tissue  are  maintained,  but  its  quantity  is  increased, 
and  thus  it  is  enabled  to  discharge  more  of  its  usual  function. 

For  a  general  expression  of  the  course  of  events,  we  may  say  that 
the  development  and  the  growth  of  the  body  go  on  together  till  all  the 
natural  structures  are  attained ;  and  that  then  development  ceases,  and 
growth  goes  on  alone,  till  the  full  stature  and  the  full  proportion  of 
each  part  to  the  rest  are  gained.  But  this  is  only  generally  true  ;  for 
we  cannot  say  that  all  development  ceases  at  a  determinate  period, 
since  some  organs  may  go  on  to  be  developed  when  many  others  are 
complete.  Neither  can  we  assign  the  period  of  terminated  growth, 
since  not  only  is  the  period,  even  stated  generally,  very  various  in 
difi'erent  persons,  but  some  parts,  unless  placed  in  unfavorable  condi- 
tions of  disease,  continue  growing  to  the  latest  period  of  life.  M.  Bizot 
and  Dr.  Clendinning  have  proved,  of  the  heart  and  arteries,  that  their 
average  size  regularly  increases,  though  with  a  decreasing  ratio  of  in- 
crease, from  childhood  to  old  age,  provided  only  the  old  age  be  a  lusty 
one.f  And  this  is  a  real  growth ;  for  the  heart  not  only  enlarges  with  ad- 

*  This  assimilating  force  is  probably  especially  exercised  by  organized  structures,  which 
may  present  those  simple  forms  which  we  recognize  as  nuclei,  or  they  may  possess  the 
more  complicated  form  of  the  cell. 

f  Croonian  Lectures  by  Dr.  Clendinning,  Medical  Gazette  for  1S37-8,  vol.  xxii,  p.  450. 


HYPEETROPHY.  65 

vanclng  years,  but  its  weight  augments,  and  the  thickness  of  its  walls 
increases  ;  so  that  we  may  believe  it  acquires  power  in  the  same  pro- 
portion as  it  acquires  bulk, — the  more  readily,  since  the  increased 
power  is  necessary  for  the  increasing  difficulties  put  in  the  way  of  the 
circulation  by  the  increasing  rigidity  of  the  parts. 

It  may  be  that  the  same  is  true  of  some  other  parts.  This  certainly 
is  true,  that  any  part,  after  it  has  attained  its  ordinary  dimensions,  ac- 
cording to  the  time  of  life,  may  grow  larger  if  it  be  more  exercised  ; 
in  other  words,  every  part  has  throughout  life,  the  power  of  growing, 
according  to  its  particular  needs,  in  correspondence  with  the  degree  in 
which  its  function  is  discharged. 

Now  when  such  growth  as  this  is  the  result  of  the  natural,  though 
almost  excessive  exercise  of  a  part  (as  of  the  limbs,  for  example,  during 
hard  work),  we  regard  it  only  as  an  indication  of  health,  and  its  result 
is  admitted  to  be  a  desirable  accession  of  strength.  But  when  such 
growth  in  one  part  is  the  consequence  of  disease  in  another,  it  is  com- 
monly described  as  a  disease ;  it  bears  the  alarming  name  of  Hyper- 
trophy, and  it  comes  to  be  a  subject  of  consideration  in  Morbid 
Anatomy. 

But  in  both  these  cases  the  process  of  growth  is  the  same,  and  is 
according  to  the  same  rules  ;  and  the  tendency  of  the  process  of  genu- 
ine hypertrophy  in  disease,  like  that  of  healthy  growth  in  active  exer- 
cise, is  always  conservative.  I  say  genuine  hypertrophy,  meaning, 
under  that  term,  to  include  only  the  cases  in  which  the  enlargement  of 
a  part  is  effected  with  development  or  increase  of  its  natural  tissue, 
with  proportional  retention  of  its  natural  form,  and  with  increase  of 
power.  To  include  all  enlargements  under  the  name  of  hypertrophy 
is  too  apt  to  lead  to  misunderstanding. 

The  rule,  then,  concerning  hypertrophy  is,  that  so  long  as  all  con- 
ditions remain  the  same,  each  part  of  the  body,  after  the  attainment 
of  the  average  size,  merely  retains  its  state,  or  at  most,  grows  at  a 
certain  determinate  slow  rate ;  but  when  the  conditions  alter,  so  that 
a  part  is  more  than  usually  exercised  in  its  office,  then  it  manifests  a 
power  of  renewing  or  accelerating  its  growth.  It  is  as  if  each  healthy 
part  had  a  reserve  power  of  growth  and  development,  which  it  puts 
forth  in  the  time  of  emergency. 

And  the  converse  is  equally  true.  When  a  part  is  less  than  usually 
exercised,  it  suffers  atrophy,  so  that  the  rule  may  be  that  each  part 
nourishes  itself  according  to  the  amount  of  function  which  it  dis- 
charges. 

We  may  constantly  see  this  rule  in  many  more  examples  than  I  need 
refer  to.  The  simplest  case  that  can  be  cited  is  that  of  the  epidermis. 
In  its  original  formation,  even  before  it  has  come  into  relation  with  the 
external  world,  it  is  formed  on  the  several  parts  of  the  body, — take  for 
example  the  back  and  the  palm  of  the  hand, — in  different  quantity  and 
kind,  adapted  to  the  several  degrees  in  which  the  cutis  it  is  to  protect 


6Q  HYPERTROPHY. 

will  be  exposed  to  pressure,  friction,  and  the  influence  of  other  external 
forces.  And  not  only  are  its  original  quantity  and  construction  on  these 
parts  different,  hut  its  rate  of  growth  is  so ;  for  though  the  back  of  the 
hand  loses  comparatively  little  by  friction  or  otherwise,  yet  its  epider- 
mis does  not  grow  thick  ;  and  though  the  palm  loses  more,  yet  its  epi- 
dermis does  not  grow  thin.  So,  then,  both  in  original  construction  and 
in  rate  of  formation,  the  epidermis  is  thus  adapted  to  the  amount  of 
function  it  has  to  discharge,  that  is,  to  the  amount  of  protection  it  has 
to  afford.  But  suppose  now  that  by  some  new  handicraft,  the  amount 
of  exercise  of  the  epidermis  is  increased,  its  rate  of  waste  is  increased 
in  the  same  proportion,  yet  it  does  not  grow  thin  ;  nay,  it  grows 
thicker,  till  it  is  completely  adapted  to  protect  the  cutis  from  the 
greater  sources  of  injury  to  which  it  is  now  exposed ;  it  puts  forth,  as 
it  were,  a  reserve  power,  which  is  enough  not  only  to  repair  all  amount 
of  waste  within  certain  limits,  but  further  than  this,  to  increase  the 
quantity  of  the  tissue  to  the  amount  required  for  the  discharge  of  its 
increased  functions. 

What  we  can  see  in  this  case  of  the  cuticle,  we  may  be  sure  of  for 
other  tissues  :  for  example,  in  a  muscle ;  as  in  a  heart,  when,  by  dis- 
ease of  the  valves,  an  obstacle  is  put  in  the  way  of  the  circulating 
blood,  and  the  heart,  or  one  of  its  cavities,  acts  with  additional  force 
to  drive  it  on.  But,  as  we  know,  the  more  of  action  in  a  muscle,  the 
more  the  consumption  of  the  tissue,  so  we  might  now  expect  a  diminu- 
tion of  the  heart.  On  the  contrary,  it  enlarges  ;  it  is  hypertrophied  ; 
the  formative  process  not  only  meets  the  immediate  exigencies  of  the 
increased  consumption  of  muscular  tissue,  but  produces  enough  to  act 
with  the  additional  power  required  by  the  increased  difficulty  of  the 
circulation. 

Such  are  the  effects  of  growth  in  examples  of  hypertrophy.  But, 
to  meet  the  increasing  difficulties  of  these  and  the  like  cases,  a  part 
may  do  more  than  grow ;  it  may  develop  itself ;  it  may  acquire  new 
structures,  or  it  may  improve  those  of  which  it  is  already  composed, 
so  as  to  become  fit  for  higher  functions  and  the  exercise  of  greater 
power.  For  example,  in  the  most  ordinary  hypertrophy  of  the  heart, 
the  muscular  tissue  is  developed  to  more  robustness  :  its  fibres  become 
not  only  larger,  or  more  numerous,  but  firmer,  more  highly  colored, 
and  stronger.  In  the  pregnant  uterus,  such  fibres  are  formed  as  are 
not  seen  in  the  unimpregnated  state ;  they  are,  indeed,  not  a  new  kind 
of  fibre,  but  they  are  so  different  in  size  and  shape,  and  so  much  more 
powerful  than  those  which  existed  before,  that  we  may  justly  speak  of 
them  as  developed.  And  this  change  by  development,  which  in  preg- 
nancy is  natural,  is  often  imitated  in  disease,  when,  by  the  growth  of 
fibrous  tumors  in  it.  the  uterus  attains  the  size,  the  structure,  and  even 
the  full  capacity  of  action,  of  the  pregnant  organ.  In  several  of  such 
cases  the  uterus  has  at  length  imitated  the  course  of  labor,  and  de- 
livered itself  of  the  tumor  by  its  contractile  power. 


HYPERTROPHY.  67 

A  similar  change,  by  development  and  growth  of  muscular  fibres, 
may  occur  in  the  gall-bladder,  the  ureter,  and,  probably,  in  any  other 
part  that  has  the  smooth  muscular  fibro-cells. 

We  have  an  example  of  development  of  a  secreting  structure  in  the 
bursa,  -which,  as  Hunter  displayed  it,  is  produced  under  a  corn.  The 
corn  itself  is  the  result  of  a  kind  of  hypertrophy,  tending  to  shield  the 
cutis  from  unnatural  pressure ;  but,  itself  becoming  a  source  of  greater 
trouble  than  that  against  which  it  was  directed,  it  gives  rise  to  the  de- 
velopment of  a  bursa  beneath  it,  which  may,  for  a  time,  more  effec- 
tually protect  the  joint  beneath,  by  diffusing  the  pressure  over  a  wider 
extent  of  surface. 

All  these  are  examples  that  this  hypertrophy,  as  we  call  it,  though  it 
happens  in  circumstances  of  disease,  is  yet  in  general,  so  far  as  itself  is 
concerned,  a  process  of  full  and  vigorous  health,  serving  to  remedy,  or 
keep  back,  the  ill  effects  that  would  ensue  from  disease  in  some  other 
part.  It  is,  in  a  less  degree  than  the  repair  of  a  fracture  or  other  me- 
chanical injury,  an  instance  of  the  truth  that  we  are  provided  for  acci- 
dents and  emergencies  ;  framed  not  merely  to  live  in  peace  and  same- 
ness, but  to  bear  disturbances ;  to  meet,  and  balance,  and  resist  them, 
and,  sometimes  at  least,  to  counteract  them. 

The  amplified  healthiness  of  the  formative  process  exercised  in  hy- 
pertrophy is  testified  by  its  requiring  a  full  measure  of  all  the  condi- 
tions of  ordinary  nutrition.  It  needs  healthy  and  appropriate  blood : 
and  one  of  the  most  interesting  studies  is  to  watch  the  hindering  influ- 
ence of  disease  on  the  occurrence  and  progress  of  hypertrophy,  espe- 
cially that  of  the  heart.  In  some  of  these  cases,  to  which  I  shall  have 
again  to  refer,  death  seems  clearly  to  be  the  consequence  of  impairment 
of  the  blood,  which  can  no  longer  maintain  in  the  heart  the  exceeding 
growth  required  for  its  increased  functions. 

We  find,  moreover,  very  constantly,  that,  as  if  to  insure  sufficient 
blood  to  the  grown  or  growing  part,  the  main  arteries  and  veins  be- 
longing to  it  are  enlarged.  This  is  usually  well  shown  in  the  en- 
larged coronary  artei'ies  of  the  hypertrophied  heart ;  an  instance  analo- 
gous to  the  enlargement  of  the  arteries  of  the  pregnant  uterus,  and  the 
growing  antlers  of  the  deer,  and  many  others.  According  to  all  ana- 
logy, we  must  consider  this  increase  of  the  bloodvessels  to  be  secon- 
dary. As  in  the  embryo,  parts  form  without  vessels,  till,  for  their  fur- 
ther nutrition  as  their  structure  becomes  more  complex,  the  passage  of 
blood  into  their  interior  becomes  necessary,  so  we  may  be  sure,  it  is 
here.  It  may  seem,  indeed,  strange  that  a  part  should  have  the  power 
of  determining  in  some  measure  the  rate  at  which  blood  shall  flow  into 
it  and  through  it ;  but  so  it  is,  and  nearly  all  examples  of  hypertrophy 
are  examples  of  the  fact ;  though,  as  I  shall  presently  have  to  mention, 
there  are  instances  in  which  hypertrophy  is  the  consequence,  not  the 
cause,  or  precedent,  of  increased  supply  of  blood. 

With  the  increased  supply  of  blood  proportioned  to  the  increased 


68  HYPERTROPHY. 

nutrition  of  the  growing  part,  the  nerves  may  also  increase  ;  as  in 
the  pregnant  uterus  and  the  hypertrophied  heart.  So,  at  least,  I  be- 
lieve ;  but  probably  I  need  not  apologize  for  evading  the  discussion  of 
this  matter. 

The  conditions  which  give  rise  to  hypertrophy  are  chiefly  or  only 
three,  namely : 

1.  The  increased  exercise  of  a  part  in  its  healthy  functions. 

2.  An  increased  accumulation  in  the  blood  of  the  particular  mate- 
rials which  a  part  appropriates  to  its  nutrition  or  in  secretion. 

3.  An  increased  afilux  of  healthy  blood. 

Of  hypertrophy  as  the  consequence  of  the  increased  exercise  of  a 
part,  I  have  already  spoken  generally ;  and  we  need  no  better  exam- 
ples of  it  than  the  muscles  of  a  strong  man's  arm,  fitted  for  the  very 
exercise  in  which  they  acquired  bulk  and  power,  or  the  great  robust 
heart  of  a  man  who  has  suffered  some  disease  producing  obstacle  to  the 
movement  of  the  blood.  Both  alike  are  the  results  of  vigorous  healthy 
growth,  brought  about  by  exercise  of  the  part  in  its  proper  function. 

In  a  former  lecture  (p.  40)  I  spoke  of  the  increased  growth  of  the 
kidney,  and  of  the  adipose  and  other  tissues,  when  the  chief  constitu- 
ents of  their  structures  exist  in  excess  in  the  blood.  To  these  I  may 
refer  again  as  examples  of  the  second  kind  of  hypertrophy.  And  I 
just  now  mentioned,  that  although  in  most  cases  an  increased  circula- 
tion of  blood  is  the  consequence  of  hypertrophy,  yet  there  are  cases  in 
which  the  course  of  events  is  inverted.  The  increased  flow  of  healthy 
blood  through  a  part,  if  it  be  not  interfered  with  by  local  disease,  will 
give  rise  to  hypertrophy  of  the  part,  or  at  least  of  some  of  its  tissues. 

This  fact  is  shown  very  well  in  a  specimen  (No.  6)  in  the  Museum, 
which  Mr.  Hunter  describes  as  "  a  sore  which  had  continued  inflamed 
a  long  time,  where  the  increased  action  had  made  the  hair  grow."  The 
integuments,  for  about  an  inch  round  the  ulcer,  where  probably  there 
was  simply  increased  supply  of  blood,  are  covered  with  thick-set,  long, 
and  rather  coarse,  dark  hairs :  while  on  the  more  distant  parts  of  the 
integuments,  the  hair  is  paler,  more  slender,  and  more  widely  scat- 
tered. 

Similar  examples  of  overgrowth  of  the  hair  through  increased  supply 
of  blood,  assisted  probably  by  more  than  usual  external  warmth  and 
moisture,  are  frequently  seen  near  the  ends  of  stumps  which  have  re- 
mained long  inflamed,  and  about  old  diseased  joints  ;  not,  indeed,  at  the 
very  seat  of  inflammation,  but  at  some  little  distance  from  it,  where 
the  parts  share  the  increased  supply  of  blood,  but  not  the  disease  of  in- 
flammation. Such  cases  are  often  observed  on  limbs  in  which  frac- 
tures have  occurred.  I  remember  one  very  striking  case  in  the  thigh 
of  a  child  about  five  years  old.  The  femur  had  been  fractured  near 
the  middle:  the  case  did  not  proceed  favorably,  and  union  was  not 
accomplished  without  much  distortion.  When  I  saw  the  child,  I  was 
at  once  struck  with  a  dark  appearance  on  the  thigh :  it  was  all  covered 


HYPERTROPHY.  69 

witli  dark  hair  like  that  of  a  strong  coarse-skinned  man  ;  yet  on  the 
rest  of  the  body,  the  hair  had  all  the  fineness  and  softness  which  are 
proper  to  it  in  early  life. 

Similar  facts  are  presented  by  some  cases  of  transplantation.  When 
the  spur  of  a  cock,  for  example,  is  transplanted  from  the  leg  to  the 
comb,  which  abounds  in  blood,  its  growth  is  marvellously  augmented, 
and  it  increases  to  a  long,  strange-looking  mass  of  horny  matter,  such  as 
is  shown  in  two  preparations  in  the  Museum  of  the  College.  In  one 
(54)  the  spur  has  grown  in  a  spiral  fashion  till  it  is  six  inches  long ;  in 
the  other  (52)  it  is  like  a  horn  curved  forwards  and  downwards,  and  its 
end  needed  to  be  often  cut,  to  enable  the  bird  to  bring  his  beak  to  the 
ground  in  feeding,  and  to  prevent  injurious  pressure  on  the  side  of  the 
neck. 

It  is  worth  observing,  that  these  excessive  growths  have  taken  place 
on  the  combs  without  any  corresponding  diminution  in  the  growth  of 
the  spurs  in  their  proper  places.  The  legs  of  these  cocks  are  amply 
spurred,  though  the  spur  reproduced  is  not  so  long  as  that  which  had 
not  been  interfered  with.  In  one  instance,  moreover  (No.  53),  there 
is  an  excessive  production  of  the  horny  scales  upon  the  legs,  while  the 
horny  spur  was  also  excessively  growing  on  the  comb. 

I  shall  have  occasion  presently  to  mention  cases  which  make  it  very 
probable  that  the  more  complex  and  vascular  tissues,  such  as  the  mus- 
cles, integuments  and  bones  of  a  limb,  can  be  thus  hypertrophied  by 
excess  of  blood.  I  will  now  only  suggest  the  probability  that  the  cases 
of  congenital  or  spontaneous  hypertrophy  of  a  hand  or  a  foot,  or  of  one 
or  more  fingers,  have  their  origin  in  some  excessive  formation  of  the 
vessels,  permitting  the  blood  to  flow  more  abundantly  through  the  part. 
An  enlargement  of  the  radial  artery  has  been  observed  by  Dr.  John 
Reid*  in  a  case  of  such  hypertrophy  of  the  thumb  and  fore-finger ;  but 
there  is  no  evidence  to  determine  whether  in  this  case  the  enlargement 
of  the  artery  was  previous  or  subsequent  to  the  excessive  growth  of  the 
part. 

Whatever  be  the  case  in  these  instances  of  enlargement,  the  fact, 
which  the  others  show,  that  well-organized  tissue,  like  hair  and  horn, 
is  produced  in  consequence  of  simply  increased  supply  of  blood,  stands 
in  interesting  contrast  with  the  phenomena  of  inflammation,  where  no 
tissue,  or  only  the  most  lowly  oi^ganized,  is  ever  formed.  No  fact  can 
better  show  how  far  the  mere  enlargement  of  the  bloodvessels  is  from 
constituting  the  essential  part  of  inflammation. 

Through  cases  of  hypertrophy,  such  as  these,  the  transition  is  made 
to  those  which,  though  they  appear  to  consist  in  simple  increase  of  the 
natural  texture  of  parts,  we  yet  must  regard  as  morbid,  inasmuch  as 
they  are  frequently  productive  of  inconvenience  to  the  individual,  and 

*  Lond.  and  Edinb.  Monthly  Journ.  of  Medical  Science,  1843,  and  in  a  collection  by  Mr. 
Curling  in  the  Med.-Chir.  Trans.,  vol.  xxviii. 


70  HYPERTROPHY 

we  do  not  know  that  they  are  adapted  to  any  exigency  of  the  economy. 
Such  are  the  simple  enlargements  of  the  thyroid,  thymus,  and  prostate 
glands,  of  the  spleen,  and  tonsils  :  such  too  are  some  examples  of  mu- 
cous polypi,  and  of  cutaneous  outgrowths  and  warty  growths  of  the 
skin.  These  all  present  an  increase  of  natural  textures  ;  and  they  may 
be  instances  of  purposive  growth,  adapted  and  conservative :  hut  till  it 
is  more  ma,nifest  that  they  are  so,  we  must  he  content,  I  think,  to  re- 
gard them  as  occupying  a  kind  of  middle  ground  between  the  genuine 
hypertrophies  of  which  I  have  been  speaking,  and  the  thoroughly  mor- 
bid outgrowths  of  which  a  part  of  the  class  of  tumors  is  composed. 

On  another  side,  there  are  cases  intermediate  between  hypertro- 
phies and  the  results  of  inflammation,  and  no  line  of  distinction  can  be 
drawn  among  them,  if  we  rely  on  their  anatomical  characters  alone  ; 
for,  in  the  lowest  degrees  of  inflammation,  the  exuded  material  may  be 
organized  into  a  very  near  likeness  to  the  natural  tissues,  and  may  thus 
seem  to  increase  their  quantity.  If  these  inflammatory  hypertrophies, 
as  they  have  been  called,  can  be  distinguished  from  true  ones,  it  is  only 
by  their  being  unattended  with  increase  of  functional  power,  or  fitness 
for  the  part's  relations. 


LECTURE  IV. 

HYPERTROPHY. 

Let  me  now  further  illustrate  the  general  physiology  of  Hypertrophy, 
by  adducing  some  of  the  specimens  in  the  Museum  which  exhibit  it  in 
the  principal  tissues. 

The  first  specimen  in  the  Pathological  division  of  the  Museum  is  a 
urinary  bladder  hypertrophied  in  consequence  of  stricture  of  the  ure- 
thra. It  afibrds  an  admirable  instance  of  genuine  unmixed  hypertro- 
phy ;  for  every  part  of  the  bladder  is  grown  large  ;  it  is  not  contracted 
as  if  it  had  been  morbidly  irritable ;  and  its  mucous  membrane,  without 
induration  or  any  similar  morbid  change,  is  increased,  apparently  by 
simple  growth,  to  a  thickness  proportionate  to  that  of  the  muscular 
coat. 

I  adduce  this  especially  as  an  example  of  hypertrophy  of  muscular 
tissue,  concerning  which,  instead  of  adding  to  what  was  said  in  the 
last  lecture,  I  will  quote  Mr.  Hunter's  account.  Referring,  perhaps, 
to  this  very  specimen,  he  says,  in  a  passage  Avhich  I  have  inserted  in 
the  Catalogue  :*  "  The  bladder,  in  such  cases  [of  obstruction  to  the 
passage  of  urine],,  having  more  to  do  than  common,  is  almost  in  a  con- 
stant state  of  irritation  and  action  ;  by  which,  according  to  a  property 

*  Vol.  i,  p.  3  ;  and  Hunter's  Works,  ii,  299. 


OFMUSCLE.  71 

in  all  muscles,  it  becomes  stronger  and  stronger  in  its  muscular  coat ; 
and  I  suspect  that  this  disposition  to  become  stronger  from  repeated  ac- 
tion is  greater  in  the  involuntary  muscles  than  the  voluntary ;  and  the 
reason  why  it  should  be  so  is,  I  think,  very  evident :  for,  in  the  invo- 
luntary muscles,  the  power  should  be  in  all  cases  capable  of  overcoming 
the  resistance,  as  the  power  is  always  performing  some  natural  and  ne- 
cessary action;  for  whenever  a  disease  produces  an  uncommon  resis- 
tance in  the  involuntary  parts,  if  the  power  is  not  proportionally  in- 
creased, the  disease  becomes  very  formidable  ;  whereas  in  the  voluntary 
muscles  there  is  not  that  necessity,  because  the  will  can  stop  whenever 
the  muscles  cannot  follow ;  and  if  the  will  is  so  diseased  as  not  to  stop, 
the  power  in  voluntary  muscles  should  not  increase  in  proportion." 

Nothing,  surely,  could  more  appositely,  or  more  exactly,  express  the 
truth,  concerning  hypertrophy  of  muscle  :  and  it  may  be  observed,  from 
what  he  says  in  a  note,  that  Mr.  Hunter  appears  to  have  been  the  first 
who  rightly  apprehended  the  nature  of  this  growth  of  the  bladder.  He 
says,  "This  appearance  was  long  supposed  to  have  arisen  from  a  disease 
of  this  viscus  ;  but,  upon  examination,  I  found  that  the  muscular  parts 
were  sound  and  distinct,  that  they  were  only  increased  in  bulk  in  porpor- 
tion  to  the  power  they  had  to  exert,  and  that  it  was  not  a  consequence  of 
inflammation,  for  in  that  case  parts  are  blended  into  one  distinct  mass." 

What  this  specimen  shows  in  the  urinary  bladder  is  an  example  of 
the  change  which  ensues  in  all  involuntary  muscles  under  the  same  cir- 
cumstances. They  all  grow  and  acquire  strength  adapted  to  the  new 
and  extraordinary  emergencies  of  their  case.  Thus,  the  oesophagus, 
the  stomach,  the  intestinal  canal,  as  often  as  any  portion  is  the  seat  of 
stricture,  display  hypertrophy  of  the  muscular  coat  above  the  stricture. 
The  enormous  enlargements  of  the  intestinal  canal,  which  gradually 
ensue  above  nearly  impassable  strictures  of  the  rectum,  are  not  mere 
dilatations,  but  growths  of  the  intestinal  walls ;  the  muscular  coat  aug- 
menting in  power,  to  overcome,  if  it  may,  the  increased  hindrance  to 
the  propulsion  of  the  contents,  and  even  the  glands  and  other  textures 
of  the  mucous  membrane  simultaneously  increasing. 

In  a  great  majority  of  cases,  the  hypertrophy  of  muscles,  whether 
voluntary  or  involuntary,  is  the  consequence  of  an  increased  obstacle 
to  their  ordinary  action.  Against  this  obstacle  they  exert  extraordi- 
nary force,  and  this  induces,  indirectly,  extraordinary  formation  of 
their  tissue.  Frequent  action  of  muscles,  unless  it  be  also  forcible, 
does  not  produce  hypertrophy.  As  Dr.  Humphry*  says,  the  heart, 
though  it  may  act  with  unusual  frequency  for  years,  yet  does  not  in 
these  cases  grow  larger  ;  and  the  muscles  of  the  hands  are  not  gene- 
rally so  large  in  mechanics  who  use  great  celerity  of  action  as  in  those 
who  work  with  great  force.  But  action  of  muscles,  if  it  be  at  once  fre- 
quent and  forcible,  may  produce  hypertrophy,  even  though  the  action 

*  Lectures  on  Surgery,  in  Prov.  Med.  and  Surg.  Journal ;   Reprint,  p.  108. 


72  HYPERTROPHY 

be  unhealthy.  This  appears  to  be  the  case  with  the  bladders  of  some 
children,  who  suffer  with  frequent  and  very  painful  micturition,  and 
all  the  signs  of  calculus,  but  in  whom  no  calculus  exists.  The  bladder 
in  such  children  is  found,  after  death,  exceedingly  hypertrophied,  and 
there  may  be  no  other  disease  whatever  of  the  urinary  organs.  Dr. 
Golding  Bird  has  shown  that  phymosis,  by  obstructing  the  free  exit  of 
urine,  may  give  rise  to  these  signs  and  to  extreme  hypertrophy  of  the 
bladder ;  but  in  some  cases  it  appears  certain  that  hypertrophy  may 
occur  without  either  phymosis,  calculus,  stricture,  or  any  similar  obstruc- 
tion. It  was  so  in  a  case  illustrated  in  the  Museum  of  St.  Bartholo- 
mew's (xxvii,  14),  in  a  child  four  years  old,  who  had  suffered  intensely 
with  signs  of  stone  in  the  bladder,  but  in  whom  no  stone  existed  ;  no  dis- 
ease of  the  urinary  organs  could  be  found,  except  this  hypertrophy  of 
the  muscular  coat  of  the  bladder.  An  exactly  similar  case  was  under 
Mr.  Stanley's  care,  in  which,  after  exceeding  irritability  of  the  bladder, 
the  enlargement  of  its  muscular  coat  appeared  the  only  change. 

In  such  cases,  the  too  frequent  and  strong  action  of  the  bladder, 
though  irritable  and  unhealthy,  seems  alone  to  give  rise  to  hypertro- 
phy of  the  fibres.  It  is,  however,  possible  that  the  change  may  be  due 
to  narrowing  of  the  urethra  by  muscular  action.  If,  for  example,  the 
compressors  of  the  urethra,  instead  of  relaxing  when  the  muscular  coat 
of  the  bladder  and  the  abdominal  muscles  are  contracting,  were  to  con- 
tract with  them,  the  obstacle  they  would  produce  in  the  urethra  would 
soon  engender  hypertrophy  of  the  bladder. 

Hunter,  whose  ingenuity  was  ever  tempting  on  his  intellect  and  in- 
dustry, asked  himself  whether  the  hypertrophy  of  the  heart  were  ac- 
complished by  the  addition  of  new  fibres,  or  by  the  enlargement  of 
those  that  already  exist,  for  it  will  be  well  to  bear  in  mind  that  hyper- 
trophy may  manifest  itself,  not  only  in  the  heart,  but  in  other  textures, 
in  one,  or  other,  of  these  two  modes,  either  by  a  simple  or  numerical 
increase.  This  question  could  hardly  be  determined  without  more  mi- 
croscopic aid  than  Hunter  had  at  his  command.  And  even  at  this 
present  time,  with  the  command  of  much  finer  means  of  investigation, 
there  appear  to  be  difliculties  in  the  way  of  answering  this  question  ; 
for  whilst  we  have,  on  the  one  hand,  Harting,*  Kolliker,f  and  Hepp| 
asserting  that  in  the  growth  of  striped  muscles  there  is  no  numerical 
increase  ;  on  the  other,  Budge,§  G.  Schmidt, |1  and  Weissman*If  positively 
state  that  new  muscular  fibres  do  arise  during  growth. 

Hypertrophy  of  bone  presents  itself  in  many  interesting  cases. 

It  is  usually  a  secondary  process,  ensuing  in  consequence  of  change 
in  a  part  with  which  some  bone  is  intimately  connected.  Just  as  in 
their  natural  development  and  growth,  the  bones  of  the  skull  are  formed 

*  Recherches  Micrometriques,  1845,  p.   62.       .         t  Micros.  Anatomie,  ii,  255. 

X  Canstatt,  1853,  p.  43.  §  Deutsche  Klinik.  April  17,  1858. 

II  Virchow's  Archiv,  1859,  vol.  18.  ^  Zeitsch.  f.  Rat.  Med.  vol.  x,  p.  263. 


'  OF     BONES.  7S 

in  adaptation  to  the  brain,  and  those  of  tlie  limbs  are  framed  to  a  fitness 
for  the  action  of  the  muscles  ;  so,  in  disease,  they  submit  in  their  nutri- 
tion to  adapt  themselves  to  the  more  active  parts.  Thus,  the  skull  en- 
larges when  its  contents  do  ;  and  the  bones  of  the  limbs  strengthen 
themselves  as  the  muscles  inserted  on  them  become  stronger  and  more 
active ;  and  they  do  this  in  adaptation  to  the  force  of  the  muscles,  and 
not  merely  because  of  the  movements  they  are  subject  to  :  for  no  extent 
or  force  of  passive  movement  would  prevent  the  bones  of  a  limb  whose 
muscles  are  paralyzed  from  suffering  atrophy. 

In  the  skull,  if  in  any  organ,  we  might  speak  of  two  forms  of  hyper- 
trophy, eccentric  and  concentric.  When  the  cranial  contents  are  en- 
larged, the  skull  is  hj^pertrophied  with  corresponding  augmentation  of 
its  area ;  and  when  the  cranial  contents  are  diminished,  the  skull  (at 
least  in  many  cases)  is  also  hypertrophied,  but  with  concentric  growth, 
and  diminution  of  its  capacity. 

The  first,  or  eccentric  form,  is  usually  the  consequence  of  hydroce- 
phalus ;  wherein,  as  the  fluid  collects  and  distends  the  dura  mater,  so 
the  skull  grows  ;  still,  as  it  were,  striving  to  attain  its  purpose,  and 
form  a  complete  envelope  for  the  expanding  brain. 

The  process  of  enlargement  in  these  cases  is  often  one  of  simple 
growth,  and  that,  indeed,  to  a  less  extent  than  it  may  seem  at  first 
sight :  for  it  is  very  rarely  that  the  due  thickness  of  the  skull  is  attained 
while  its  bones  are  engaged  in  the  extension  of  their  superficial  area. 
Hence,  the  weight  of  a  hydrocephalic  skull  is  not  much,  if  at  all, 
greater  than  that  of  a  healthy  one  ;  a  large  parietal  bone,*  measurino- 
nine  inches  diagonally,  weighs  only  four  ounces,  while  the  weight  of  an 
ordinary  parietal  bone  is  about  three  ounces. 

It  is  interesting  to  observe,  in  some  of  these  cases,  the  symmetrical 
placing  of  the  Wormian  bones,  by  which  the  extent  of  the  skull  is  in 
a  measure  made  up.  They  show  how  the  formative  process,  though 
thus  thrown  into  straits  and  dijSiculties,  yet  conforms,  both  in  growth 
and  development,  with  the  law  of  symmetry. 

It  would  be  yet  more  interesting  if  we  could  certainly  trace  here 
something  of  conformity  with  the  law  of  unity  of  organic  type,  in  the 
mode  of  insertion  of  these  Wormian  intercalary  bones,  when  compared 
Avith  those  of  other  animals.  It  cannot  be  certainly  done  ;  and  yet,  in 
some  of  these  specimens,  there  appears  (as  if  in  accordance  with  that  law) 
a  tendency  to  the  formation  of  the  Wormian  bones  at  the  posterior  part 
of  the  sagittal  suture  more  than  in  any  other  part,  as  if  in  imitation  of 
the  interparietal  bones  of  Rodents.  And  in  the  very  rare  specimenf 
sketched  in  the  diagram  (Fig.  3),  in  the  midst  of  great  confusion  of  the 
other  bones,  we  find  a  remarkable  bony  arch,  extending  from  between 
the  two  frontals  to  the  occipital  bone  ;  occupying,  therefore,  the  place 

*  No.  2  in  the  College  Museum.  f  No.  3487  in  the  same  Museum. 


74 


HYPERTROPHY 


riff.  3. 


of  a  large  interparietal  bone,  and  reminding  us  of  some  of  the  monkeys, 
e.g-  Cebus  and  Jacchus.     We  have  a  somewhat  corroborative  sj^ecimen 

in  the  inmmense  hydroce- 
phalic skull  of  the  skeleton 
from  Mr.  Liston's  Museum 
(No.  3489),  in  which  the  in- 
terparietal Wormian  bones 
are  larger  than  any  others. 
The  hypertrophy  of  the 
skull,  which  may  be  called 
concentric,  is  that  which 
attends  atrophy  with  shrink- 
ing of  the  brain,  or  perhaps, 
any  disease  of  the  brain  in 
which  there  is  diminution  of 
its  bulk.  In  such  a  case  it  usually  happens,  as  was  first  shown  by  Dr. 
Sims,*  that  the  skull  becomes  very  thick. 

All  the  specimens  which  I  have  examined  show,  however,  that  in 
these  cases  the  thickening  of  the  skull  is  not  in  itself  a  morbid  process  ; 
it  manifests  definite  purpose  ;  is  usually  effecteil  by  healthy  growth ; 
and  observes  the  rules  followed  in  the  natural  formation  of  the  sk,ull. 

Thus,  as  in  its  first  formation,  the  skull  adapts  itself  to  the  form  and 
size  of  the  brain,  or  rather,  of  its  membranes  ;  only  now  it  does  so 
without  representing  on  its  exterior  the  change  which  has  taken  place 
within.  The  thickening  of  the  skull  is  effected  by  the  gradual  remodel- 
ling of  the  inner  table  and  diploe  of  the  bones  of  the  vault ;  so  that, 
although  the  exterior  of  the  skull  may  retain  its  natural  form  and  size, 
the  inner  table  grows  more  and  more  inwards,  as  if  sinking  towards  the 
retiring  and  shrinking  brain ;  not  thickening,  but  simply  removing 
from  the  outer  table,  and  leaving  a  Avider  space  filled  with  healthy 
diploe. 

Again,  it  is  a  fact  of  singular  interest,  that  this  thickening,  this 
hypertrophy  of  the  skull,  most  commonly,  if  not  always,  takes  place 
especially,  and  to  a  greater  extent  than  elsewhere,  in  the  parts  of  the 
bones  in  and  about  which  ossification  commenced  in  the  foetal  state  ;  as 
if,  one  might  say,  some  of  the  potency  that  of  old  brought  the  foetal 
membrane  of  these  parts  first  into  the  development  of  bone,  were  always 
afterwards  concentrated  in  them ;  or  as  if  a  reserve  power  of  growth 
had  its  seat  in  the  same  centres  where  was  formerly  the  originative 
power  of  development.  The  fact  is  showm  in  many  of  the  specimens, 
especially  in  one  that  is  represented  in  Fig.  4 ;  and  we  may  find  some 
further,  though  less  sure  evidence  of  the  peculiar  formative  energy 
of  these  old  centres,  in  the  fact  that  those  diseases  of  bone  which  are 
accompanied  with  excessive  formation,  such  as  morbid  thickenings  of 


*  Medico-Chirurgical  Transactions,  vol.  xix,  p.  315. 


OF    BONES. 


75 


the  skull  and  tumors  are,  in  a  large  majority  of  cases,  seated  in  or 
near  the  centres  of  ossification;  you  rarely  find  them,  except  at  the 
articular     ends,    or 

round  the  middle  of  Fig.  4. 

the  shaft.  The  same 
does  not  hold  of  ne- 
crosis, rickets,  ulce- 
ration, or  other  dis- 
eases indicative  of 
depression  of  the 
formative  power  of 
the  bone.  Rather, 
as    some    specimens 

(Nos.  390-1-2)  of  ricketty  disease  of  the  skull  and  femora  show,  the 
centres  of  ossification  are  remarkably  exempt  from  the  change  of  struc- 
ture which  has  extensively  affected  the  later-formed  parts. 

This  peculiarity  of  the  centres  of  ossification  is  the  more  remarkable 
when  we  remember  that  in  many  cases,  the  thickening  of  the  skull 
takes  place  in  persons  far  past  the  middle  period  of  life  ;  it  may  happen 
even  in  very  old  age,  and  may  give  one  more  evidence  of  that  precision 
of  assimilation  which  maintains,  throughout  life,  characteristic  distinc- 
tions among  portions  of  what  we  call  the  same  tissue. 

Let  me,  however,  remark,  that  it  is  not  peculiar  to  old  persons  :  I 
believe  that  at  whatever  age,  after  the  complete  closure  of  the  cranial 
sutures,  shrinking  of  the  brain  may  happen,  this  hypertrophy  of  the 
skull  may  be  its  consequence.  One  specimen,  for  instance  (No.  379), 
is  part  of  the  skull  of  a  suicide  only  thirty  years  old ;  another  (No. 
380),  from  an  idiotic  woman,  has  not  the  characters  of  an  old  skull.  I 
once  examined  a  remarkable  case,  showing  the  same  conditions,  in  a 
person  less  than  thirty  years  old,  in  whom  the  thickening  of  the  skull 
must  have  begun  in  early  life.  She  was  a  lady  of  remarkable  personal 
attractions,  but  of  slenderly  developed  intellect,  whose  head  did  not, 
externally,  appear  below  the  average  female  size.  Yet  her  cranial 
cavity  was  singularly  contracted  ;  the  skull  had  adapted  itself  to  an 
imperfectly  grown  brain,  by  the  hypertrophy  of  its  diploe,  which  Avas 
nearly  half  an  inch  thick  at  and  near  the  centres  of  ossification  of  the 
frontal  and  parietal  bones.  But  this  cranial  hypertrophy,  does  not 
necessarily  affect  the  whole  of  the  bones  forming  the  walls  of  the  brain 
cavity.  It  may  be  limited  in  extent,  as  in  those  cases  in  which  a  par- 
tial atrophy  of  the  contents  of  the  cavity  occurs,  as  when  one  hemi- 
sphere only  of  the  cerebrum  or  cerebellum  is  diminished  in  size.* 

Such  hypertrophy,  however,  is  not  always  the  mode  by  which  the 
skull  is  adapted  to  the  diminished  size  of  th«  brain.  In  congenital  and 
very  early  atrophy  of  the  brain,  the  skull  is  proportionally  small,  and 


*  An  interesting  case  of  this  liincl  has  been  recorded  by  Prof.  S.  Van  der  Kolk.     Essay- 
translated  in  vol.  xi,  of  New  Syd.  Soc.  Publications,  ]861. 


76  HTPERTROPHY 

may  exactly  represent  the  size  and  shape  of  the  cerebrum.  It  does  so 
in  the  cases  of  small-skulled  idiots,  and  in  a  remarkable  skull  in  the 
Museum  of  St.  Bartholomew's  Hospital.  The  man  from  whom  this 
skull  was  taken  received  a  compound  fracture  of  the  left  frontal  bone 
when  he  was  only  fourteen  years  old.  Portions  of  bone  were  removed  ; 
hernia  cerebri  ensued,  and  several  pieces  of  brain  were  sliced  off.  But 
he  recovered,  and  lived  thirty-three  years.  The  left  hemisphere  of  the 
cerebrum  was  altogether  small.  Where  the  brain  had  been  sliced  off, 
its  surface  had  sunk  in  very  deep,  and  had  left  a  cavity  filled  with  a 
vascular  spongy  substance  containing  ill-formed  nerve-fibres.  You  will 
observe  here,  that  in  the  modelling  of  the  skull,  the  left  side  has  become 
in  every  part  less  capacious  than  the  right,  adapting  itself  to  the  di- 
minished brain  without  any  hypertrophy  of  the  bones. 

The  cases  are  very  rare  in  which  hypertrophy  of  any  other  bones 
than  those  of  the  skull  occurs  in  connection  with  what  is  recognized  as 
disease.  For,  as  I  have  said,  the  bulk  of  most  of  the  other  bones  is 
principally  determined  by  the  activity  of  the  muscles  fixed  on  them  ; 
and  a  morbidly  excessive  action  of  muscles,  sufficiently  continued  to 
produce  hypertrophy  of  bones,  is  seldom,  if  ever,  met  with. 

But  there  is  a  condition  of  bones  so  similar  to  hypertrophy  in  many 
respects,  and  so  little  different  from  it  in  any,  that  I  may  well  speak  of 
it  here ;  yet  not  without  acknowledging  that  nearly  all  I  know  about  it 
is  derived  from  Mr.  Stanley. 

When  any  of  the  long  bones  of  a  person  who  has  not  yet  attained 
full  stature  is  the  seat  of  disease  attended  with  unnatural  flow  of  blood 
in  or  near  it,  it  may  become  longer  than  the  other  or  more  healthy 
bone.  For  example,  a  lad,  suppose,  has  necrosis  of  the  femur,  it  may 
be  of  a  small  portion  of  it,  and  he  may  recover  completely  from  this 
disease  ;  but  for  all  his  life  afterwards  (as  I  had  constant  opportunity 
once  of  observing  in  a  near  relative),  he  may  be  lame,  and  the  charac- 
ter of  his  lameness  will  show  that  the  limb  which  was  diseased  is  now 
too  long ;  so  that  he  is  obliged,  in  walking,  to  lift  the  lame  leg,  almost 
like  a  hemiplegic  man,  lest  his  toe  should  trip  upon  the  ground. 

Such  cases  are  not  uncommon.  I  once  saw,  with  Mr.  Stanley,  a 
member  of  our  profession,  in  whom  this  elongation  of  one  femur  had 
taken  place  to  such  an  extent  that  he  was  obliged  to  wear  a  very  high 
shoe  on  the  other ;  that  is,  the  healthy  limb.  And  this,  which  he  had 
adapted  for  himself,  affords  the  only  remedy  for  the  inequality  of  limbs. 
ISTor  is  the  remedy  unimportant ;  for  to  say  nothing  of  the  unsightly 
lameness  which  it  produces,  the  morbid  elongation  of  the  limb  is  apt  to 
be  soon  complicated  by  one  or  two  serious  consequences.  Either  the 
patient  in  his  endeavors  to  support  himself  steadily  and  upright,  will 
acquire  first  the  habit,  and  then  the  malformation  of  talipes  of  the 
healthy  limb  ;  or  else,  through  the  habit  of  always  resting  on  the  short, 
healthy,  and  stronger  limb,  he  will  have  lateral  curvature  of  the  spine. 
Cases  of  both  these  kinds  have  occurred  in  Mr.   Stanley's  practice ; 


OF    BONES. 


77. 


Fis:.  5. 


being  brought  to  him  for  the  remedy,  not  of  the  elongated  femur,  but 
of  the  consequent  deformity  of  the  foot  or  the  spine. 

A  considerable  elongation  of  the  lower  extremity  almost  always  de- 
pends on  the  femur  being  thus  affected :  another,  and  very  characteris- 
tic result,  ensues  from  the  same  kind  of  hypertrophy  when  it  occurs  in 
the  tibia.  The  femur  can  grow  longer  without  materially  altering  its 
shape  or  direction,  but  the  tibia  is  tied  by  ligaments  at  its  two  ends  to 
the  fibula  ;  so  that  when  it  lengthens,  unless  the  fibula  should  lengthen 
to  the  same  extent,  it,  the  tibia,  must  curve ;  in  no  other  way  except 
by  the  lengthening  of  the  ligaments,  which  I  believe  never  happens  to 
any  considerable  extent,  is  elongation  of  the  tibia  possible. 

Tibiae  thus  curved  are  far  from  rare  ;  specimens  are  to  be  found  in 
nearly  every  museum  ;  yet  I  know  of  none  in  which  the  pathology  of 
the  disease  is  clearly  shown,  except  one  in  the 
Museum  at  St.  Bartholomew's  (Subser.  A,  46), 
which  is  here  sketched,  Fig.  5.  In  this,  the 
fibula,  and  healthy  tibia  of  the  opposite  limb, 
are  preserved  with  the  elongated  tibia.  The  an- 
terior wall  of  this  tibia,  measuring  it  over  its 
curve,  is  more  than  two  inches  longer  than  that 
of  the  healthy  one  :  the  posterior  wall  is  not 
quite  so  long. 

In  all  such  specimens  you  may  observe  a 
characteristic  form  of  the  curve,  and  its  distinc- 
tion from  the  curvature  of  rickets.  The  dis- 
tinction is  established  by  these  particulars  :  the 
ricketty  tibia  is  always  short ;  the  other  is  never 
short,  and  may  be  longer  than  is  natural :  in  the 
ricketty  one  the  articular  ends  always  enlarge 
very  suddenly,  for  the  shortening  is  due  to  the 
imperfect  formation  of  the  ends  of  the  shaft ;  in 
the  elongated  tibia,  there  is  usually  even  less 
contrast  of  size  between  the  shaft  and  epiphyses 
than  is  natural,  because  the  elongation  of  the 
shaft  is  commonly  attended  with  some  increase 
of  its  circumference:  but,  especially,  the  ricketty 
tibia  is  compressed,  usually  curved  inwards,  its 
shaft  is  flattened  laterally,  and  its  margins  are 
narrow  and  spinous ;  while  in  the  elongated  tibia, 
the  curve  is  usually  directed  forwards,  its  mar- 
gins are  broad  and  round,  its  surfaces  are  convex,  and  the  compression 
or  flattening,  if  there  be  any,  is  from  before  backwards. 

The  elongation  of  the  bones  in  these  cases  may  occur,  in  diflerent 
instances,  in  two  ways.  In  some  cases  it  seems  due  to  that  change  in 
bone  which  is  analogous  to  chronic  inflammation  of  soft  parts,  and 
which  consists  in  the  deposit  of  the  products  of  inflammation  in  the  in- 


78  HYPERTROPHY 

terstices  of  the  osseous  tissue,  their  accumulation  therein,  and  the  re- 
modelling of  the  bone  around  them  as  they  accumulate.  Such  a  change 
appears  to  have  occurred  in  the  specimen  from  which  the  sketch  was 
taken,  and  would  necessarily  give  rise,  in  a  growing  bone,  as  it  does 
in  soft  parts,  to  enlargement  in  every  direction,  to  elongation  as  well 
as  increase  of  circumference. 

But  in  other  cases,  the  elongation  is  probably  due  to  the  more  genu- 
ine hypertrophy  which  follows  the  increased  flow  of  blood.  When,  for 
example,  a  small  portion  of  bone,  as  in  circumscribed  necrosis,  is  ac- 
tively diseased,  all  the  adjacent  part  is  more  vascular ;  hence  may  arise 
a  genuine  hypertrophy,  such  as  I  have  shown  in  hair  under  similar 
circumstances.  Or,  when  an  ulcer  of  the  integuments  has  long  ex- 
isted in  a  young  person,  the  subjacent  bone  may  share  in  the  increased 
afflux  of  blood,  and  may  enlarge  and  elongate.  Even,  it  appears,  when 
one  bone  is  diseased,  another  in  the  same  limb  may  thus  be  increased 
in  length.  A  remarkable  instance  of  this  kind  has  lately  been  observed 
by  Mr.  Holden,  in  a  young  man,  who,  in  childhood,  had  necrosis  of  the 
left  tibia,  one  of  the  consequences  of  which  was  defective  growth  of  the 
left  leg,  with  shortening  to  the  extent  of  more  than  an  inch.  Yet  the 
whole  limb  is  not  shorter  than  the  other  ;  for,  without  any  apparent 
morbid  change  of  texture,  the  femur  of  the  same  side  has  grown  so  as 
to  compensate  for  the  shortening  of  the  tibia. 

An  interesting  example  of  similar  increased  growth  of  one  bone,  in 
compensation  for  the  weakness  of  another,  is  found  sometimes  in  cases 
of  ill-repaired  fractures  or  diseases  of  the  tibia.  The  fibula,  at  the  part 
corresponding  with  the  weak  portion  of  the  tibia,  is  in  such  cases 
strengthened  sufiiciently  for  the  support  of  the  limb.  So  in  a  specimen 
in  the  Museum  of  St.  Bartholomew's  (Ser.  3 ;  86),  taken  from  a  dog 
ten  weeks  after  a  piece  of  the  radius  was  cut  out  with  its  periosteum, 
while  the  gap  in  the  radius  is  filled  with  only  soft  tissue,  the  exactly 
corresponding  portion  of  the  ulna  is  increased  by  the  formation  of  new 
bone  beneath  its  periosteum. 

I  must  not  forget  to  say,  that  the  interest  of  these  cases  of  inequality 
of  the  limbs,  by  lengthening  of  one  of  the  bones,  is  increased  by  com- 
parison with  another  class  of  cases  in  which  a  great  or  greater  inequality 
of  length  depends  on  one  limb  being  anormally  short.  In  these  the 
short  limb  has  been  the  seat  of  atrophy,  through  paralysis  of  the  mus- 
cles dependent  on  some  of  the  very  numerous  conditions  in  which  they 
may  be  rendered  inactive.  The  complication  of  the  cases,  the  talipes, 
and  the  curvatures  of  the  spine,  depending,  as  they  do,  on  the  ine- 
quality of  the  length  of  the  limbs,  from  whatever  cause  arising,  will  be 
alike  in  both ;  and  much  care  may  be  needed  in  diagnosis,  to  tell  which 
of  the  limbs,  the  long  one  or  the  short  one,  is  in  error.  The  best  cha- 
racters probably  are,  that  when  a  limb  is,  through  disease  or  atrophy, 
too  short,  it  will  be  found,  in  comparison  with  the  other,  defective  in  cir- 
cumference as  well  as  in  length;  its  muscles,  partaking  of  the  atrophy, 


CAUSED    BY    PRESSURE.  79 

will  be  weak  and  flabby,  and  all  its  tissues  will  bear  signs  of  imperfect 
nutrition.  If  none  of  these  characters  be  found  in  the  short  limb,  the 
long  one  may  be  suspected  ;  and  this  suspicion  will  be  confirmed,  if 
there  be  found  in  it  the  signs  of  increased  nutrition,  such  as  enlarge- 
ment, growth  of  hair,  and  the  rest :  or  if,  in  the  history  of  the  case, 
there  be  evidence  of  a  disease  attended  with  an  excess  in  the  supply  of 
blood. 

Continuing  to  select  from  the  Museum  only  such  examples  of  hyper- 
trophy as  may  illustrate  its  general  pathology,  I  pass  over  many,  and 
take  next,  those  which  display  the  formation  of  corns  ;  a  subject  which, 
while  Hunter  deemed  it  worth  consideration,  we  shall  not  be  degraded 
by  discussing.  He  made  many  preparations  of  corns,  to  show  not  only 
the  thickening  of  the  cuticle,  but  the  formation  of  the  little  sac  of  fluid, 
or  bursa,  between  the  thickened  cuticle  and  the  subjacent  articulation. 
His  design  appears  to  have  been  mainly,  to  illustrate  the  different 
results  of  pressure ;  to  show  how  that  which  is  from  without  produces 
thickening ;  that  from  within,  thinning  and  absorption  of  parts.  He 
says,  having  regard  to  these  specimens,  "  The  cuticle  admits  of  being 
thickened  from  pressure  in  all  parts  of  the  body  ;  hence  we  find  that  on 
the  soles  of  the  feet  of  those  who  walk  much,  the  cuticle  becomes  very 
thick ;  also  on  the  hands  of  laboring  men.  We  find  this  wherever 
there  is  pressure,  as  on  the  elbow,  upper  part  of  the  little  toe,  ball  of 
the  great  toe,  &c.  The  immediate  and  first  cause  of  this  thickening 
would  appear  to  be  the  stimulus  of  necessity  given  to  the  cutis  by  this 
pressure,  the  effect  of  which  is  an  increase  of  the  cuticle  to  defend  the 
cutis  underneath.  Not  only  the  cuticle  thickens,  but  the  parts  under- 
neath ;  and  a  sacculus  is  often  formed  at  the  root  of  the  great  toe,  be- 
tween the  cutis  and  ligaments  of  the  joint,  arising  from  the  same  cause, 
to  guard  the  ligaments  below."* 

In  another  place  he  says,  "  When  from  without,  pressure  rather 
stimulates  than  irritates ;  it  shall  give  signs  of  strength,  and  produce 
an  increase  of  thickening  :  but,  when  from  within,  the  same  quantity  of 
pressure  will  produce  waste"  [as  illustrated  in  Nos.  120  and  121  in  the 
Pathological  Museum] ;  "  for  the  first  effect  of  the  pressure  from  with- 
out is  the  disposition  to  thicken,  which  is  rather  an  operation  of 
strength  ;  but  if  it  exceeds  the  stimulus  of  thickening,  then  the  pressure 
becomes  an  irritator,  and  the  power  appears  to  give  way  to  it,  and 
absorption  of  the  parts  pressed  takes  place;  so  that  Nature  very  readily 
takes  on  those  steps  which  are  to  get  rid  of  an  extraneous  body,  but 
appears  not  only  not  ready  to  let  extraneous  bodies  enter  the  body,  but 
endeavors  to  exclude  them  by  increasing  the  thickness  of  the  parts. "f 

It  is  evident  from  these  passages  that  Mr.  Hunter  was  aware  that 
pressure  from  without  might  produce  atrophy ;  though  he  may  appear 

*  Hunter's  Works,  vol.  i,  p.  560.  -f  Ibid.  vol.  iii,  p.  466. 


80         HYPERTROPHY:  EFFECTS  OF  PRESSURE. 

to  favor  the  belief,  which,  I  think,  is  commonly  adopted  as  on  his  au- 
thority, that  the  direction  of  the  pressure  is  that  which  determines  its 
result.  Really,  the  result  seems  to  depend  more  on  whether  the  pres- 
sure be  occasional  or  constant.  Constant  extra  pressure  on  a  part 
always  appears  to  produce  atrophy  and  absorption ;  occasional  pressure 
may,  and  usually  does,  produce  hypertrophy  and  thickening.  All  the 
thickenings  of  the  cuticle  are  the  consequences  of  occasional  pressure ; 
as  the  pressure  of  shoes  in  occasional  walking,  of  tools  occasionally 
used  with  the  hand,  and  the  like :  for  it  seems  a  necessary  condition 
for  hypertrophy,  in  most  parts,  that  they  should  enjoy  intervals  in 
which  their  nutrition  may  go  on  actively.  But  constant  pressure, 
whether  from  within  or  from  without,  always  appears  to  give  rise  to 
unrepaired  absorption  :  and  most  museums  contain  interesting  examples 
of  its  effects. 

Some  vertebree  in  the  College  Museum  (121  A.)  illustrate  very  well 
the  results  of  pressure  by  aneurisms  and  tumors.  So  far  as  themselves 
are  concerned,  the  pressure  of  the  aneurism  was  from  without  inwards ; 
yet  they  are  atrophied  ;  not  ulcerated,  but  hollowed  out,  and  remodelled 
in  adaptation  to  the  shape  of  the  aneurismal  sac  :  their  cancellous  tissue 
is  not  exposed,  but,  as  in  the  natural  state,  is  covered  by  a  complete 
thin  external  layer  of  compact  tissue. 

The  pressure  of  a  loose  mass  of  bone  in  the  knee-joint  (No.  955  in 
the  same  Museum)  was  from  without  inwards ;  but  its  result  was  atro- 
phy, as  shown  in  the  formation  of  a  deep  pit  at  the  lower  end  of  the 
femur,  in  which  it  lay  safely  and  almost  tightly  lodged. 

Again,  the  effect  of  constant  pressure  is  shown  in  the  cases  in  which 
one  of  the  lower  incisor  teeth  of  a  rodent  animal  has  continued  its 
growth  after  the  loss  of  the  corresponding  upper  incisor,  and,  being  no 
longer  worn  down  by  attrition  in  growing,  attains  an  unnatural  length. 
In  such  a  case  the  extremity  of  the  tooth,  turning  round  so  as  to  form 
nearly  a  complete  circle,  has  come  in  contact  with  the  side  of  the  lower 
jaw,  and  (like,  as  they  tell,  the  Fakir's  finger-nails  growing  through 
the  thickness  of  his  clenched  hand)  it  has  perforated  the  whole  thick- 
ness of  the  jaw  ;  the  absorption  consequent  on  its  pressure,  making  way 
for  its  onward  course. 

A  yet  stranger  example  was  taken  from  the  body  of  a  woman  in  the 
dissecting-room  of  St.  Bartholomew's  Hospital,  and  the  specimen  (Ser. 
1  ;  232)  tells  all  the  history  that  can,  or  perhaps  need,  be  given.  She 
had  an  aperture  in  the  hard  palate,  and  for  remedy  of  its  annoyance 
used  to  wear  a  bung,  or  cork,  in  it.  But  the  constant  pressure  of  so 
rough  an  obturator  produced  absorption  of  the  edges  of  the  opening, 
making  it  constantly  larger,  and  requiring  that  the  cork  should  be  often 
wound  round  with  tape  to  fit  the  widening  gap.  And  thus  the  remedy 
went  on  increasing  the  disease,  till,  of  all  the  palatine  portions  of  the 
upper  maxillary  and  palate  bones,  nothing  but  their  margin  or  outer 
shell  remains :   the  rest  is  all  absorbed.     The  antrum  is  on  each  side 


ATROPHY:     DEGENEEATION.  81 

obliterated  by  the  apposition  of  its  walls,  its  inner  wall  having  probably 
been  pushed  outwards  as  the  plug  was  enlarged  to  fit  the  enlarging 
aperture  in  the  palate.  Nearly  the  whole  of  the  vomer  also  has  been 
destroyed,  and  the  superior  ethmoidal  cells  are  laid  open. 

Lastly,  as  an  instance  in  which,  in  the  same  part,  permanent  pressure 
produced  atrophy  and  occasional  pressure  hypertrophy,  I  may  show  a 
Chinese  woman's  foot.  The  bandaging,  and  constant  compression  in 
early  life,  produced  this  diminished  growth  ;  but  afterwards,  when, 
with  all  the  miserable  doublings-up  and  crowding  of  the  toes,  the  foot 
was  used  in  walking,  the  parts  of  pressure  became  the  seats  of  corns. 

We  may  sometimes  observe  the  same  contrast  after  amputations.  A 
hole  may  be  absorbed  in  an  upper  flap  where  it  lies  on  the  end  of  the 
bone,  and  is  subject  to  the  constant  pressure  of  its  own  weight ;  but,  in 
older  stumps,  the  greater  occasional  pressure  on  the  artificial  limb  leads 
to  thickening  and  hardening  of  the  parts. 

These  examples,  then,  may  suffice  to  show,  as  I  have  said,  that  con- 
stant pressure  on  a  part  produces  absorption  ;  occasional  pressure  (espe- 
cially if  combined  with  friction)  produces  thickening  or  hypertrophy  ; 
and  that  these  result  whatever  be  the  direction  of  the  pressure.  And, 
yet,  let  me  add  that  Mr.  Hunter  was  not  far  wrong, — he  never  was  ; 
for  nearly  all  pressures  from  without  are  occasional  and  intermittent, 
and  nearly  all  pressures  from  within,  arising,  as  they  do,  from  the 
growth  of  tumors,  the  enlargement  of  abscesses,  and  the  like,  are 
constant. 


LECTUEE   V. 

ATROPHY  :    DEGENERATION. 

I  PROPOSE  now  to  consider  the  subject  of  Atrophy ;  the  very  con- 
trary of  the  hypertrophy  which  I  endeavored  to  elucidate  in  the  last 
two  lectures. 

By  atrophy  is  commonly  implied,  not  the  cessation  or  total  privation 
of  the  formative  process  in  a  part,  but  its  deficiency ;  and,  as  I  limited 
hypertrophy  to  the  cases  in  which  an  increased  power  is  acquired  for  a 
part  by  the  growth,  or  by  the  development,  of  healthy  tissue  ;  so  shall 
atrophy  be  here  taken  to  mean  only  that  process  by  which  a  part  either 
simply  wastes  and  is  reduced  in  size,  with  little  or  no  change  of  texture, 
or  else,  gradually  and  regularly  degenerates. 

By  the  terms  of  this  limitation  it  is  implied,  that,  as  there  are  two 
modes  of  hypertrophy,  the  one  with  growth,  the  other  with  develop- 
ment ;  so  there  are  two  modes  of  atrophy,  the  one  with  simple  decrease, 
the  other  with  degeneration,  of  tissue.  In  both,  there  is  a  loss  of  func- 
tional power  in  the  part ;  but  in  one,  this  loss  is  due  to  the  deficient 
quantity,  in  the  other  to  the  deteriorated  quality,  of  the  tissue.     But, 


82  ATROPHY: 

as  in  hypertrophy  the  development  and  the  growth  of  the  affected  part 
usually  concur,  so,  in  atrophy,  a  part  which  becomes  smaller  usually 
also  degenerates,  and  one  which  degenerates  usually  becomes  smaller. 
Still,  one  or  other  of  these,  either  the  decrease  or  the  degeneration, 
commonly  prevails ;  and  we  shall  see  reasons  why  the  distinction  is 
very  necessary  to  he  made. 

Let  me  first  state,  and  even  at  some  length,  what  is  to  be  understood 
by  degeneration,  and  how  its  effects  may  be  distinguished  from  those  of 
disease. 

I  implied  in  a  former  lecture,  that  the  maintenance  of  a  part  in  its 
nutrition  must  not  be  understood  as  being  the  maintenance  of  an  un- 
changed state :  rather,  each  part  may  be  said  to  present  a  series  of 
minute  progressive  changes,  slowly  effected  and  consistent  with  that 
exercise  of  its  functions  which  is  most  appropriate  to  the  successive 
periods  of  its  existence. 

ISTow,  after  a  certain  length  of  life,  these  changes  accumulate  into  a 
very  noticeable  deterioration  of  all,  or  nearly  all,  parts  of  the  body  ; 
and  they  suffer  a  manifest  loss  of  functional  power.  Thus  changed, 
we  say  they  are  degenerate:  these  accumulated  changes  are  the  signs 
of  decay,  the  infirmities  of  age,  the  senile  atrophy.  They  are  the  indi- 
cations of  defective  formative  power,  and  often  speak  more  plainly  of 
old  age  than  do  the  years  a  man  may  have  counted  ;  they  testify  that 
the  power  which  prevailed  over  the  waste  of  the  body  in  childhood  and 
youth,  and  maintained  the  balance  in  vigorous  manhood,  has  now 
failed :  as  the  tide,  after  a  flood  and  a  period  of  rest,  turns  and  ebbs 
down. 

All  the  expressions  usually  employed  about  these  changes  imply  that 
they  are  not  regarded  as  the  results  of  disease :  nor  should  they  be  ; 
they  are,  or  may  be,  completely  normal ;  and  were  it  not  that  the  forces 
which  are  efficient  in  degeneration  are,  probably,  very  different  from 
those  which  actuate  the  formative  processes,  we  might  justly  call  the  de- 
generation of  advanced  age  another  normal  method  of  nutrition.  For, 
to  degenerate  and  die  is  as  normal  as  to  be  developed  and  live  :  the  ex- 
pansion of  growth  and  the  full  strength  of  manhood,  are  not  more 
natural  than  the  decay  and  feebleness  of  a  timely  old  age ;  not  more 
natural,  because  not  more  in  accordance  with  constant  laws,  as  observed 
in  ordinary  conditions.  As  the  development  of  the  whole  being,  and 
of  every  element  of  its  tissues,  is  according  to  certain  laAVS,  so  is  the 
whole  process  regulated  by  which  all  that  has  life  will,  as  of  its  own 
workings,  cease  to  live.  The  definition  of  life  that  Bichat  gave  is,  in 
this  view,  as  untrue  as  it  is  illogical.  Life  is  so  far  from  being  "  the 
sum  of  the  functions  that  resist  death,"  that  it  is  a  constant  part  of  the 
history  of  life  that  its  exercise  leads  naturally  to  decay,  and  through 
decay  to  death. 

Of  the  manner  in  which  this  decay  or  degeneration  of  organisms  en- 
sues we  know  but  little.     Till  within  the  last  few  years  the  subject  of 


DEGENERATION.  '  83 

degenerations  was  scarcely  pursued :  and  even  of  late,  the  inquiries, 
which  ought  to  range  over  the  whole  field  of  living  nature,  have  been 
almost  exclusively  limited  to  the  human  body. 

Yet,  it  could  not  be  without  interest  to  watch  the  changes  of  the 
body  as  life  naturally  ebbs  ;  changes,  by  which  all  is  undone  that  the 
formative  force  in  development  achieved  ;  by  which  all  that  was  gath- 
ered from  the  inorganic  world,  impressed  with  life,  and  fashioned  to  or- 
ganic form,  is  restored  to  the  masses  of  dead  matter ;  to  trace  how  life 
gives  back  to  death  the  elements  on  which  it  had  subsisted ;  the  pro- 
gress of  that  decay  through  which,  as  by  a  common  path,  the  brutes 
pass  to  their  annihilation,  and  man  to  immortality.  Without  a  know- 
ledge of  these  things  our  science  of  life  is  very  partial,  very  incomplete. 
And  the  study  of  them  would  not  lack  that  peculiar  interest  which  ap- 
pertains to  inquiries  into  final  causes.  For  all  the  changes  of  natural 
decay  or  degeneration  in  living  beings  indicate  this  design ;  that,  being 
gradual  approximations  to  the  inorganic  state  of  matter,  they  lead  to 
conditions  in  which  the  elements  of  the  body,  instead  of  being  on  a  sud- 
den and  with  violence  dispersed,  may  be  collected  into  those  lower  com- 
binations in  which  they  may  best  rejoin  the  inorganic  world ;  they  are 
such,  that  each  creature  may  be  said  to  die  through  that  series  of 
changes  which  may  best  fit  it,  after  death,  to  discharge  its  share  in  the 
economy  of  the  world,  either  by  supplying  nutriment  to  other  organ- 
isms, or  by  taking  its  right  part  in  the  adjustment  of  the  balance  held 
between  the  organic  and  the  inorganic  masses. 

Nor  would  the  student  of  the  design  of  these  degenerations  do  well  to 
omit  all  thought  of  their  adaptation,  in  our  own  case,  to  the  highest 
purposes  of  our  existence.  When,  in  the  progress  of  the  "  calm  decay" 
of  age,  the  outAvard  senses,  and  all  the  faculties  to  which  they  minister, 
grow  dim  and  faint,  it  may  be  on  purpose  that  the  Spirit  may  be  in- 
vigorate and  undisturbed  in  the  contemplation  of  the  brightening 
future ;  that,  with  daily  renewed  strength,  it  may  free  itself  from  the 
incumbrance  of  all  sensuous  things,  or  may  retain  only  those  fragments 
of  thought  or  intellectual  knowledge  which,  though  gathered  upon 
earth,  yet  bear  the  marks  of  truth,  and  being  Truth,  may  mingle  with 
the  Truth  from  Heaven,  and  form  part  of  those  things  in  which  Spirits 
of  infinite  purity  and  knowledge  may  be  exercised. 

Moreover  (and  this  is  in  the  closest  relation  to  my  present  subject), 
the  changes  of  natural  degeneration  in  advanced  life  have  a  direct  im- 
portance in  all  pathology  ;  because  they  may  guide  us  to  the  interpreta- 
tion of  many  similar  anomalies  which,  while  they  occur  in  earlier  life, 
we  are  apt  to  call  diseases,  but  which  are  only  premature  degenerations, 
and  are  to  be  considered,  therefore,  as  methods  of  atrophy  ;  as  defects, 
rather  than  as  perversions,  of  the  nutritive  process  ;  or  as  diseases,  only 
in  consideration  of  the  time  of  their  occurrence.* 

*  One  can  here  have  in  view  only  the  cases  in  which  the  degeneration  affects  the  whole, 
or  some  considerable  part,  of  an  organ;  for  it  is  very  probable  that  some  of  the  degenera- 


84  ATROPHY: 

The  changes  that  mark  the  progress  of  natural  decay  or  degeneration 
in  old  age,  and  that  may,  therefore  be  regarded  as  the  typical  instances 
of  simple  defective  nutrition,  seem  to  be  these :  1.  Wasting  or  wither- 
ing ;  the  latter  term  may  imply  the  usually  coincident  wasting  and 
drying  which  constitute  the  emaciation  of  a  tissue.  2.  Fatty  degenera- 
tion, including  many  of  what  have  been  called  granular  degenerations. 
3.  Earthy  degeneration,  or  calcification.  4.  Pigmental  degeneration. 
5.  Thickening  of  primary  membranes. 

Of  each  of  these  let  me  cite  one  or  two  examples. 

Of  withering,  or  wasting  and  drying,  which  is  perhaps  the  commonest 
form  of  atrophy,  we  have  abundant  instances  in  the  emaciation  of  old 
age ;  in  which,  while  some  parts  are  removed  by  complete  absorption, 
others  are  only  decreased  in  size,  and  lose  the  succulency  of  earlier  life. 
But  this  withering  atrophy  must  not  be  confounded  with  the  mere  dry- 
ing and  collapse  of  tissues,  which  ensue  in  cases  in  which  fluids  are  dis- 
charged in  excessive  quantity,  as  in  cholera,  diabetes,  and  hemorrhage. 
A  good  illustration  of  the  natural  withering  of  the  elementary  structures 
of  a  part  is  afforded  in  the  hardening  and  drying  (cornification)  of  the 
epithelial  cells.  This  is  especially  exhibited  by  the  tessellated  epithe- 
lium and  cuticle,  the  cells  of  which,  in  their  progress  from  the  deeper 
to  the  superficial  layers,  not  only  become  harder  and  dryer,  previous  to 
their  final  separation,  but  assume  a  flattened,  withered  aspect. 

The  fatty  degeneration  in  senility  is  best  shown,  as  a  general  occur- 
rence, in  the  increasing  obesity  which  some  present  at  the  onset  of  old 
age,  and  in  the  general  fact  that  there  is  more  fatty  matter  in  all  the 
tissues,  and  most  evidently  in  the  bones,  than  there  is  in  earlier  life ; 
while,  as  local  senile  fatty  degenerations,  we  find  the  arcus  senilis,  or 
fatty  degeneration  of  the  cornea,  and  the  accumulating  fatty  or  athero- 
matous degenerations  of  arteries. 

The  calcareous  degeneration  is,  in  old  age,  displayed  in  the  gradual 
increasing  proportion  of  earthy  matter  in  the  bones ;  in  the  extension 
of  ossification  to  cartilages,  which,  in  all  the  period  of  vigor,  had  re- 
tained their  embryonic  state ;  and  in  the  increasing  tendency  to  earthy 
deposits  in  the  arteries,  and  other  parts. 

It  may  manifest  itself  in  one  or  other  of  two  ways,  either  as  a  creti- 
fication,  that  is,  a  mere  deposition  of  lime  salts,  or  as  a  true  ossification, 
that  is,  accompanied  by  the  formation  of  lacunae  and  canajiculi,  cancel- 
lated, and  compact  tissue,  and  even,  in  some  cases,  periosteum.  In 
most  instances  these  two  forms  are  so  well  marked,  and  the  differences 
between  them,  both  to  the  naked  eye  and  the  microscope,  are  so  obvious, 
that  there  can  be  no  difficulty  in  distinguishing  one  from  the  other. 
The  simple  calcareous  deposit  possesses  no  definite  structure,  and  is 

tions  which  we  see  en  masse  in  the  organs'of  the  old,  or  in  the  seats  of  premature  defect  of 
nutrition,  are  the  same  as  occur  naturally  in  the  elementary  structures  or  molecules  of 
organs,  when  the  term  of  their  natural  life  is  ended,  previous  to  their  being  absorbed  and 
replaced,  as  it  were  by  one  particle  at  a  time,  in  the  regular  process  of  nutrition. 


DEGENEKATION.  85 

generally  so  fragile  as  readily  to  crumble  down  beneath  the  fingers, 
whilst  the  true  ossific  formation  presents  all  the  well-known  characters 
of  bone.  But  it  is  not  unusual  to  meet  with  instances  of  calcareous 
degeneration  in  which  it  is  not  so  easy  to  pronounce  with  certainty  if 
the  formation  be  true  bone  or  not.  In  these  cases  the  substance  may 
be  hard  and  compact,  but  the  existence  of  a  lacunary  structure  is  not 
very  decided.  Small  dark-looking  spaces,  appearing  like  very  imper- 
fectly formed  lacunse,  may  occasionally  be  seen,  irregular  in  size,  shape, 
and  arrangement,  and  destitute  of  canaliculi.  These  remind  one  some- 
what of  the  imperfect  structures  met  with  in  the  cement  and  granu- 
lar layer  of  the  crusta  petrosa  of  the  fang  of  a  tooth.  Probably  the 
best  test  of  the  lacunary  nature  of  these  irregular  spaces  would  be 
the  detection  in  them  of  nuclei,  such  as  are  found  in  the  lacunae  of 
true  bone. 

The  tendons  not  unfrequently  exhibit  true  bony  growths  in  their  in- 
terior, which  may  either  spring  from  the  surface  of  attachment  and 
extend  for  a  greater  or  less  distance  into  their  interior,  or  may  exist 
as  distinct  isolated  masses  in  their  substance.  In  the  muscles,  also, 
very  extensive  bony  growths  occasionally  take  place.  Mr.  Hawkins* 
has  recorded  a  very  curious  case,  in  which  there  was  a  most  extensive 
formation  of  bone  in  the  voluntary  muscles,  and  there  is  in  the  Museum 
of  the  College  a  preparation  in  which  nearly  all  the  muscles  of  the  back 
have  undergone  ossification.  Whether  in  cases  such  as  these  the  bone 
is  formed  in  the  muscular  fibre  itself,  or  originates  in  the  connective 
tissue  between  the  fibres,  and  by  its  growth  produces  through  pres- 
sure atrophy  and  destruction  of  the  proper  muscular  substance,  has 
been  made  a  matter  of  question,  but  there  are  very  strong  grounds  for 
believing;  the  latter  to  be  the  case  ;  the  formation  of  bone  in  connective 
tissue  being  a  well-recognized  fact  in  development. 

The  pigmental  degeneration  has  its  best  instances  in  the  gradually 
accumulating  black  pigment,  spotting  and  streaking  the  lungs ;  in  the 
slate  or  ash  color  which  is  commonly  seen  in  the  thin  mucous  mem- 
branes of  the  stomach  and  intestines  of  old  persons  ;  in  pigmental  dis- 
oolorations  of  the  skin,  which  are  manifested  in  their  highest  form, 
though  not  necessarily  occurring  in  old  persons,  in  apparent  connection 
with  disease  of  the  supra-renal  capsules,  as  first  pointed  out  by  Dr. 
Addison ;  in  the  black  spotting  of  the  arteries  of  some  animals,  in 
which  pigment  seems  to  hold  the  place  of  the  fatty  degeneration  so 
usual  in  our  own  arteries, f  and  under  some  as  yet  imperfectly  under- 
stood conditions,  in  the  accumulation  of  pigment  in  considerable  quan- 

*  Med.  Gaz.,  vol.  xxxiv,  1844,  p.  273. 

f  In  Virchow's  Archiv.,  1859,  vol.  xvi,  p.  564,  an  abstract  is  given  of  an  inaugural  dis- 
sertation by  Von  Stein,  in  which  it  is  stated  that  in  sixty-two  cases  of  diseases  of  the  brain 
which  he  examined,  pigment  was  deposited,  mostly  in  the  middle  and  outer  coats  of  the 
vessels,  in  no  less  than  fifty-three  cases. 


86  ATROPHY: 

titles,  not  merely  in  the  walls  of  the  bloodvessels,  but  even  in  the  tubes 
themselves.* 

Of  the  tliichening  of  primary  membranes  we  have  indications  in  the 
usual  thickening  of  the  tubules  of  the  testes,  and,  I  think,  of  some 
other  glands,  as  their  function  diminishes  in  old  age ;  in  the  opaque 
white  thickening  of  the  primary  or  inner  membrane  of  nearly  all  blood- 
vessels ;  and  in  the  thickening  of  the  wall  of  the  cartilage-cells  in  senile 
and  some  other  ossifications.  To  this,  also,  we  have  a  strong  analogy 
in  the  thickening  of  the  cell-Avalls  of  the  heart- wood  of  plants. 

These  changes,  singly  or  in  various  combinations,  constitute  the  most 
evident  degenerations  of  old  age  in  man.  Their  combinations  give  rise 
to  numerous  varieties  in  their  appearance ;  such  as,  e.  g.^  the  increase 
of  both  fatty  and  earthy  matter  in  old  bones ;  the  dry,  withered,  and 
darkly-tinged  condition  of  the  epidermis  ;  the  coincident  fatty  and  cal- 
careous deposits  in  the  arteries  ;  the  thickened  walls  and  fatty  contents 
of  the  seminal  tubes.  But  at  present,  I  need  not  dwell  on  these,  nor 
on  the  conditions  which  determine  the  occurrence  of  one  rather  than 
another  mode  of  degeneration ;  for  these  I  cannot  tell. 

Now  if  we  observe  the  conditions  in  which  these  senile,  and  there- 
fore typical,  examples  of  degeneration  are  imitated  in  earlier  life,  they 
are  such  as  indicate  that  the  changes  are  still  to  be  ascribed  to  a  defect, 
not  to  a  perversion,  of  the  conditions  of  nutrition  or  of  the  vital  forces. 

Thus,  these  changes  are  all  especially  apt  to  occur  in  a  part  of  which 
the  functions  are  abrogated :  a  motionless  limb  wastes  or  becomes  fatty 
as  surely  as  an  old  one  does.  They  are  found  ensuing  when  one  or 
more  of  the  conditions  of  nutrition  are  removed,  not  changed.  For 
example,  a  fatty  degeneration  of  part  of  a  heart  may  ensue  when, 
through  disease  of  a  coronary  artery,  its  supply  of  blood  is  diminished. 
They  often  occur  in  parts  that  fail  to  attain  the  development  for  which 
they  seemed  to  be  intended.  Thus  fatty  degeneration  usually  ensues 
in  the  cells  of  unfruitful  Graafian  vesicles,  f  In  short,  all  their  history, 
when  we  can  trace  it,  is  that  of  atrophies. 

We  may  therefore  safely  hold,  that  as  the  changes  to  which  the 
several  tissues  are  naturally  prone  in  old  age  are  certainly  the  results 
of  defect,  not  of  perversion,  of  the  nutritive  process,  so  are  the  cor- 
responding changes  when  they  happen  in  earlier  life,  although,  through 
their  appearing  prematurely,  they  may  bear  the  features  of  disease. 

The  distinction  between  degeneration  and  disease  is  essential,  though 
often  it  may  be  obscure.  Degeneration,  as  to  its  process,  is  natural, 
though  it  may  be  premature  ;  disease  is  always  unnatural :  the  one  has 

*  A  lengthened  account  of  this  form  of  pigment  deposit  in  the  capillaries,  especially  of 
the  liver,  spleen,  brain,  and  other  viscera,  has  been  given  by  Frerichs  in  his  Clinical  Trea- 
tise on  Diseases  of  the  Liver.  In  the  Medico-Chirurgical  Review,  1861  (vol.  xxvii),  Dr. 
Laycock  has  published  an  article  on  morbid,  cutaneous,  pigmentary  changes,  in  w^hich  the 
question  of  pigment  deposits  is  discussed  very  fully. 

-j-  Reinhardt,  in  Traube's  Beitriige,  B.  i,  p.  145. 


DEGENERATION.  87 

its  origin  within,  the  other  without  the  body :  the  one  is  constant,  the 
other  as  various  as  the  external  conditions  in  which  it  may  arise  :  to 
the  one  we  are  prone,  to  the  other  only  liable. 

The  general  diagnostic  characters  of  degenerations  are  chiefly  these : 

1.  They  are  such  changes  as  may  be  observed  naturally  occurring, 
in  one  or  more  parts  of  the  body,  at  the  approach  of  the  natural 
termination  of  life,  or  if  not  then  beginning,  yet  then  regularly  in- 
creasing. 

2.  They  are  changes  in  which  the  new  material  is  of  lower  chemical 
composition,  i.  e.,  is  less  remote  from  inorganic  matter,  than  that  of 
which  it  takes  the  place.  Thus  fat  is  lower  than  any  nitrogenous  organic 
compound,  and  gelatine  lower  than  albumen,  and  earthy  matter  lower 
than  all  these. 

3.  In  structure,  the  degenerate  part  is  less  developed  than  that  of 
which  it  takes  the  place  :  it  is  either  more  like  inorganic  matter,  or  less 
advanced  beyond  the  form  of  the  mere  granule  or  the  simplest  cell. 
Thus,  the  approach  to  crystalline  form  in  the  earthy  matter  of  bones, 
and  the  crystals  in  certain  old  vegetable  cells,  are  characteristic  of 
degeneration ;  and  so  are  the  granules  of  pigment  and  of  many  granular 
degenerations,  and  the  globules  of  oil  that  may  replace  muscular  fibres 
or  the  contents  of  gland-cells,  and  the  crystals  of  cholesterine  that  are 
often  mingled  with  the  fatty  and  earthy  deposits, 

4.  In  function,  the  part  has  less  power  in  its  degenerate  than  in  its 
natural  state. 

5.  In  its  nutrition,  it  is  the  seat  of  less  frequent  and  less  active 
change,  and  without  capacity  of  growth,  or  of  development. 

Such  are  the  characters  by  which  in  general  we  might  separate  the 
processes  and  results  of  degeneration  from  those  of  disease,  and  of 
natural  nutrition.  But  we  must  remember  always  that  the  process  of 
degeneration  may  concur  with  either  of  those  from  which,  in  its  typical 
examples,  it  may  be  so  clearly  separated.  It  may  mingle  with  develop- 
ment ;  or,  at  least,  by  a  process  of  degeneration,  a  part  may  become 
adapted  to  a  more  developed  condition  of  the  system  to  which  it  belongs. 
So  it  is  in  the  process  of  ossification.  It  is  usual  to  speak  of  cartilage 
as  being  developed  into  bone,  and  to  regard  bone  as  the  more  developed 
and  more  highly  organized  of  the  two  tissues.  But  I  think  it  is  only  in 
a  very  limited  sense  that  this  mode  of  expression  is  just.  Professor 
Owen,  in  some  admirable  remarks*  on  the  cartilaginous  state  of  the 
endo-skeleton  of  Chondropterygian  fishes,  has  said:  "I  know  not  why 
a  flexible  vascular  animal  substance  should  be  supposed  to  be  raised  in 
the  histological  scale  because  it  has  become  impregnated,  and,  as  it 
were,  petrified  by  the  abundant  intussusception  of  earthy  salts  in  its 
areolar  tissue.  It  is  perfectly  intelligible  that  this  accelerated  progress 
to  the  inorganic  state  may  be  requisite  for  some  special  ofiice  of  such 

*  Lectures  on  Comparative  Anatomy,  vol.  ii,  p.  146. 


88  atrophy: 

calcified  parts  in  the  individual  economy ;  but  not,  therefore,  that  it  is 
an  absolute  elevation  of  such  parts  in  the  series  of  animal  tissues."  Let 
me  add,  that  all  that  one  sees  of  the  life  of  cartilage,  in  the  narrower 
survey  of  the  higher  mammalia,  is  conformable  with  this  view,  and 
would  lead  us  to  speak  of  its  change  into  bone  as  a  degeneration,  rather 
than  a  development.  The  change  is  effected  not  only  in  the  vigor  of 
life,  but  as  constantly,  in  certain  parts,  in  its  decay ;  and,  whenever  it 
is  effected,  the  part  that  has  become  bone  almost  ceases  to  grow,  except 
by  superaddition :  the  interstitial  changes  of  normal  nutrition  are 
reduced  to  their  lowest  stage.  Cartilage,  too,  is  less  frequently  and 
less  perfectly  repaired  after  injury  than  bone  is ;  and  its  repair  is  com- 
monly effected  by  the  production  of  bone ;  yet  it  is  contrary  to  all 
analogy  for  a  lower  tissue  to  be  repaired  by  the  formation  of  a  higher 
one.  It  may  be  added  that  the'  granular,  and  in  some  instances  even 
crystalline,  form,  in  which  the  earthy  matter  of  bone  is  deposited,  is 
inconsistent  with  the  supposition  that  its  animal  matter  has  acquired  a 
higher  development  than  it  had  before  in  the  state  of  cartilage.  So  far, 
therefore,  as  its  position  in  the  series  of  animal  tissues  is  concerned, 
bone  should  be  placed  below  cartilage ;  as  a  tissue  which  has  degene- 
rated into  a  state  of  less  active  life,  and  has  acquired  characters  that 
approximate  it  to  the  more  lowly  organized  and  to  the  inorganic  sub- 
stances. An  osseous  skeleton  is,  indeed,  proper  to  the  most  highly 
developed  state  of  the  individual,  and  in  this  relative  view  bone  appears 
superior  to  cartilage ;  but,  with  as  much  right,  in  the  same  view,  the 
atrophied  thymus  gland,  and  the  renal  capsules  almost  arrested  in  their 
growth,  might  claim  to  be  regarded  as  developments  from  their  foetal 
state;  for  these,  also,  are  normal  parts  of  the  more  perfect  organism; 
they  are  like  the  degenerate  members  of  an  ennobled  society,  except  in 
that,  in  their  humiliation,  they  augment  the  common  weal. 

The  points  of  contact,  and  even  of  complete  fusion,  are  yet  more 
numerous  between  degeneration  and  disease.  In  many  diseases,  proba- 
bly even  in  the  whole  class  of  inflammations,  a  degeneration  of  the 
affected  tissue  is  a  constituent  part  of  the  morbid  process  ;  and  in  many 
cases  we  must  still  doubt  whether  the  changes  of  texture  that  we  ob- 
serve are  the  results  of  degeneration  or  of  disease.  Among  these  are 
the  instances  of  the  simple  softening  of  certain  organs,  such  as  the 
brain  and  spmal  cord,  and  the  liquefactions  of  inflammatory  exudations 
in  the  suppurative  process.  If  we  limit  the  term  degeneration  to  the 
changes  that  imitate  the  typical  examples  of  old  age,  these  changes 
cannot  be  included  under  it ;  but  they  may  be  if  we  consider  the  con- 
ditions in  which  they  occur,  and  the  mere  decrease  of  power  which  some 
of  them  manifest.  The  softening  of  the  brain  and  spinal  cord,  for 
example,  occurs  in  some  cases  through  mere  defect  of  blood ;  in  some 
through  mere  abrogation  of  function ;  it  is  often  concurrent  with  dis- 
tinct signs  of  atrophy ;  and,  as  I  shall  describe  in  the  next  lecture,  it 
is  attended  with  changes  that  closely  imitate  those  of  fatty  degenera- 


DEGENERATION.  89 

tion.  On  the  whole,  therefore,  while  admitting  the  difficulty  that  must 
often  occur  in  endeavoring  to  separate  such  changes  as  these  from  the 
effects  of  disease,  or  of  local  death,  yet  I  think  we  should  do  well  to 
classify  them  under  such  a  title  as  that  of  "  liquefactive  degenera- 
tion."* 

*  This  is  perhaps  the  best  place  to  advert  to  a  peculiar  pathological  condition,  to  which 
much  attention  has  been  of  late  years  directed,  under  the  name  of  Amyloid  degeneration. 
It  must  be  confessed,  however,  that  its  pathological  history  is,  at  present,  very  defective,  so 
that  we  are  but  imperfectly  acquainted,  not  only  with  the  exact  nature  of  the  substance 
found  in  this  so-called  degeneration,  but  even  with  the  conditions  under  which  its  formation 
takes  place.  Neither  can  we  say  with  any  certainty,  that  it,  like  the  degenerations  already 
enumerated  (p.  84),  marks  the  progress  of  natural  decajr,  or  degeneration  in  old  age. 
Although  the  name  "  amyloid"  has  been  but  recently  given  by  Virchow  to  the  substance 
which  produces  the  peculiar  waxy,  or  sago-like  appearance,  so  characteristic  of  the  presence 
of  amyloid,  in  the  organs  or  textures,  yet  in  its  best  marked  forms,  at  least,  the  occasional 
existence  of  an  abnormal  material  in  them  had  been  already  recognized,  and  described  as 
the  lardaceous,  or  waxy  degeneration.  Virchow  had  in  the  first  instance  observed  (Ar- 
chiv,  vol.  vi,  p.  135),  that  when  iodine  was  added  to  the  rotmd  concentric  bodies  found  in 
the  ependyma  of  the  ventricles  of  the  brain,  a  blue  color  was  produced,  which  was  changed 
to  a  beautiful  violet  on  the  addition  of  sulphuric  acid.  From  these  reactions  he  supposed 
that  these  structures  were  of  the  nature  of  cellulose,  and  he  named  them  corpora  amylacea. 
He  subsequently  extended  his  researches  to  morbid  textures  (Archiv,  vol.  vi,  et  seq.),  and 
found  that  when  a  solution  of  iodine  was  brushed  over  the  surface  of  parts  presenting  the 
wax-like  change,  that  a  dark  yellowish-red  color  was  produced,  which,  on  the  careful  addi- 
tion of  sulphuric  acid,  was  converted  to  a  blue  or  violet.  Certain  resemblances  in  color, 
imder  the  use  of  the  same  reagents,  were  thus  shown  to  exist  between  the  corpora  amyla- 
cea of  the  brain  and  the  peculiar  material  present  in  the  waxy  degeneration,  from  which  it 
was  supposed  that  an  identity,  or  close  resemblance  in  chemical  composition,  existed  be- 
tween them.  These  conclusions  of  Virchow  respecting  the  chemical  nature  of  this  material 
are  far  from  being  generally  accepted  by  pathologists,  amongst  whom  there  is  much 
difference  of  opinion  as  to  its  composition.  And,  indeed,  it  is  not  difHcult  to  see  why  such 
diversities  of  opinion  should  exist,  when  we  consider  how  it  is  incorporated  with  the  sub- 
stance of  the  normal  textures ;  how  hard  it  must  therefore  be  to  free  it  from  them  and  from 
blood,  so  as  to  isolate  it  in  sufficient  quantities  for  analysis.  Thus  we  find  that  H.  v. 
Meckel  (Annal.  des  Charite  Krank.  Jahrgang,  iv)  argues  in  favor  of  its  being  cholesterine. 
C.  Schmidt,  again  (Annalen  der  Chemie,  B.  ex,  p.  250),  concludes  from  his  analyses  that  it 
is  not  an  oxy-hydrocarbon  analogous  to  the  non  nitrogenous  cellulose,  but  a  nitrogen-contain- 
ing compound.  He  was  unable  to  convert  it  into  sugar.  Messrs.  Bristowe  and  Ord  (Trans. 
Path.  Soc.  Lond.,  vol.  x)  are  inclined  to  regard  it  as  allied  rather  to  fibrine  than  to  amyla- 
ceous matters.  Dr.  Harris  (On  the  Nature  of  the  Substance  found  in  the  Amyloid  Degene- 
ration, 1860)  considers  that  its  reactions  indicate  its  analogy,  not  its  perfect  identity,  with 
the  substances  of  the  amylaceous  group.  Whilst  Billroth  (Beitrage  zur  Path.  Histologie) 
thinks  that  it  is  proved  that  amyloid  is  neither  pure  cholesterine,  nor  pure  starch  or 
cellulose,  but  a  body  of  complex  composition,  the  exact  nature  of  which  has  yet  to  be 
discovered. 

But,  whatever  be  its  chemical  composition,  there  can  be  no  doubt  that  a  substance, 
presenting  the  reactions  with  iodine  and  sulphuric  acid  already  described,  is  under  some 
pathological  conditions  most  extensively  distributed  in  the  organs  and  textures  of  the  body. 
It  has  been  especially  demonstrated  in  the  liver,  spleen,  kidneys,  lymphatic  glands,  intestinal 
canal,  and  even  in  cartilage.  It  occurs  as  an  amorphous,  homogeneous  material,  infiltrated 
into  the  very  substance  of  the  texture,  and  primarily  affects  the  small  arteries,  in  the  fibro- 
cells  of  the  middle  coat  of  which  it  is  apparently  first  deposited.  The  arterial  walls  in  this 
manner  gradually  become  thickened,  and  the  calibre  of  the  vessel  diminished  so  that  the 
part  assumes  an  ansemic  appearance.     From  the  bloodvessels  it  may  extend  to  the  proper 

7 


90  FATTY    DEGENERATION. 

The  sum  of  this  discussion  respecting  degenerations  is  as  follows : 
We  observe  certain  changes  naturally  ensuing  in  the  tissues  during 
advanced  age,  and  we  ascribe  these  to  defect,  not  to  disorder,  of  the 
formative  process  :  we  notice  the  same  or  similar  changes  in  earlier  life, 
and  we  refer  them  to  a  similar  defect,  and  class  them  as  methods  of 
atrophy  ;  we  seem  justified  in  thus  regarding  them,  by  the  general  fact 
that  they  often  have  the  same  origin,  and  are  concurrent,  with  the 
atrophy  which  is  attended  with  merely  defective  quantity  of  tissue ;  and 
lastly,  we  regard  certain  changes  of  texture,  such  as  some  forms  of 
softening  of  organs,  as  degenerations  or  atrophies,  because,  though  they 
are  not  natural  in  old  age,  they  occur  in  nearly  the  same  conditions, 
and  manifest  some  of  the  same  characters,  as  the  atrophies  which 
imitate  those  of  senility. 

Among  the  degenerations  that  I  have  enumerated,  that  which  may 
best  be  used  for  general  illustration  of  the  whole  process,  is  the  fatty. 
This  deserves  a  full  description,  first,  because  of  its  own  great  impor- 
tance in  pathology,  for  there  is  scarcely  a  natural  structure  or  a  pro- 
duct of  disease  in  which  it  may  not  occur ;  and  secondly,  for  its 
illustration  of  the  general  doctrine  of  defective  nutrition,  and  for 
guidance  in  the  study  of  the  degenerations  that  are  at  present  less 
understood.  For  we  may  be  nearly  sure,  that  general  truths,  deduced 
from  examples  of  fatty  degeneration,  will  hold  equally  of  the  other 
forms,  and  especially  of  the  calcareous  and  pigmental ;  between  which 
and  the  fatty  degenerations  there  are  so  many  obvious  features  of  close 
resemblance,  that  I  shall  content  myself,  having  enumerated  them,  with 

tissues  of  the  organs,  and  exist  in  the  secreting  cells  of  a  gland  so  as  to  communicate  the 
peculiar,  dull,  semitransparent,  wax-like  appearance  to  the  texture. 

But  although  sufficient  evidence  has  not  yet  been  adduced  to  justify  one  in  concluding 
that  the  amorphous  material  infiltrated  into  the  substance  of  parts  in  the  amyloid  degenera- 
tion is  cellulose  or  starch,  yet  there  appear  to  be  strong  grounds  for  supposing  that  starch, 
in  its  granular  or  corpuscular  form,  may  exist  in  the  normal  textures.  The  corpuscula 
amylacea,  already  referred  to  as  occurring  in  the  brain,  are  regarded  by  several  trustv/orthy 
observers  as  true  starch-corpuscles.  Mr.  Busk  (Quart.  Jal.  Mic.  Science,  Jan.,  1854)  was 
the  first  who  distinctly  affirmed,  from  their  structural,  physical,  and  chemical  properties, 
this  correspondence ;  and  Virchow  himself,  who  at  one  time  regarded  them  as  cellulose, 
now  looks  upon  them  as  exhibiting  a  complete  analogy  to  vegetable  starch.  (Cellular 
Pathologie,  Lect  xiii.)  In  the  prostate  gland,  also,  jjeculiar  laminated  concretions  have  long 
been  known,  which  give  to  iodine  the  blue  reaction  of  starch,  and  which,  as  Paulizky  has 
recently  shown  (Virchow's  Archiv,  vol.  xvi,  p.  147,  1859),  can,  by  means  of  saliva,  be  con- 
verted into  sugar.  Dr.  Carter  (Edin.  Med.  Jal.,  August,  1855,  and  March,  1858)  not  only 
pronounces  the  corpora  amylacea  to  be  starch,  but  contends,  and  adduces  many  observations 
in  support  of  his  statement,  that  starch  granules  are  extensively  distributed  in  the  tissues 
and  organs  of  the  body,  and  that  they  are  physiological  products  of  the  animal  organism. 
Dr.  Carter  has  also  observed  their  presence  in  certain  pathological  new  formations,  and  Dr. 
Beale  has  found  numerous  bodies  exactly  resembling  starch  granules  in  a  cancerous  liver. 
(Gulstonian  Lectures,  p.  91.)  Mr.  Lockhart  Clarke  has  also  noticed  a  considerable  deposi- 
tion of  the  corpora  amylacea  around  the  central  canal  in  a  case  of  disease  of  the  spinal 
cord.   (Beale's  Archives,  October,  1861.) 


FATTY    DEGENERATION.  91 

merely  referring  to  the  examples  of  them  that  will  be  described  in  future 
lectures.* 

The  anatomical  characters  of -many  examples  of  fatty  degeneration 
will  be  described  in  the  next  and  in  subsequent  lectures.  Their  princi- 
pal general  feature  is,  that  in  the  place  of  the  proper  substance  of  an 
elemental  structure,  e.  g.^  in  the  place  of  the  contents  or  the  nucleus  of 
a  cell,  or  in  the  very  substance  of  a  simple  membrane, -a  blastema,  or  a 
fibre,  minute  particles  or  granules  are  seen,  which  are  recognized  as 
consisting  of  oily  or  fatty  matter,  by  their  peculiar  refraction  of  light, 
their  solubility  in  ether,  their  aptness  to  coalesce  into  larger  oil-drops, 
and,  when  they  are  very  abundant,  by  the  greasiness  of  the  whole 
tissue,  its  burning  with  a  bright  flame,  and  its  yielding  to  analysis  an 
unusual  quantity  of  fatty  matter.  In  examining  organs  in  the  state  of 
fatty  degeneration,  we  may  commonly  see  the  progress  of  the  change 
in  the  gradual  increase  of  the  fatty  particles.  Some  cells,  for  example, 
may  appear  quite  healthy ;  some  may  deviate  from  health  only  in  con- 
taining two  or  three  shining,  black-bordered,  oil-particles ;  in  others, 
these  are  increased,  and  a  large  part  of  the  cell-cavity  is  filled  with 
minute  oil-particles,  or  with  one  or  more  larger  oil-drops ;  and  in  others, 
the  contents  of  the  cell  have  given  place  to  a  single  cluster  of  oil-drops. 
In  this  last  case,  the  degeneration  is  nearly  complete :  the  transformed 
cell  is  called  a  "granule-cell,"  or,  when,  as  it  often  happens,  the  cell- 
wall  has  wasted  and  disappeared,  it  is  a  "granule-mass;"  and  the  last 
stage  of  degeneration  is  that  such  masses  may  break  up,  their  con- 
stituent molecules  may  dispart,  and  the  tissue  which  was  an  aggregate 
of  nucleated  cells  may  become  little  more  than  a  mass  of  molecules  or 
drops  of  oily  matter. 

It  is  probably  due  in  part  to  such  disintegration  of  degenerate  cells, 
that,  in  most  organs  thus  degenerate,  abundant  fatty  matter  is  found 
free,  that  is,  lying  in  drops  not  enclosed,  among  the  proper  constituents 
of  the  tissue.  But  this  free  fat  is  also  derived,  in  part,  from  the 
degeneration  of  intercellular  substance,  which  is  usually  concurrent 
with  that  ensuing  in  the  cells ;  and  in  some  cases  (as  Virchow  has 
observed  in  the  liver)  it  so  follows  the  arrangement  of  minute  blood- 
vessels that  it  may  be  considered  as  the  residue  of  a  direct  deposit  from 
them. 

In  most  instances  the  fatty  degeneration  affects,  first  and  chiefly,  as 
I  have  described  it,  the  contents  of  cells  or  tubules,  or  the  proper  sub- 
stance of  membrane  or  other  tissue.  And  when  it  thus  happens,  the 
nuclei  almost  always  waste,  and  either  shrivel  or  disappear  after 
gradually  fading  in  their  outlines.  This  may  be  commonly  seen  in  the 
fatty  degeneration  of  the  renal  and  hepatic  cells,  and  of  the  muscular 
fibres ;  and  it  is  a  fact  of  some  significance,  when  we  remember  the 
constancy  and  abundance  of  nuclei  in  actively  growing  parts.     But,  in 

*  The  index  will  afford  at  once  a  sufficient  guide  to  these  examples. 


92  FATTY    DEGENERATION. 

certain  cases,  as  in  fatty  degeneration  of  cartilages,  the  change  appears 
to  begin  in  the  nuclei,  which  are  gradually  transformed  into  granule 
masses,  while  the  cell-wall  may  remain  unchanged,  or  may  become 
thickly  walled  or  laminated,  or  may  coalesce  with  the  surrounding 
tissue. 

Such  a  transformation  of  a  nucleus,  while  it  retains  its  place  and 
general  form,  might  at  once  suggest  that  the  fatty  matter  which  collects 
in  these  degenerations  is  not  introduced  from  without  into  the  cells  or 
other  elements  of  the  tissues ;  that  it  is  not  placed  in  them,  as  it  may 
be  in  the  parts  around  them,  as  a  morbid  deposit,  but  rather  is  one  of 
the  products  and  residues  of  some  chemical  transformation  which  they 
undergo  when  the  proper  nutritive  changes  are  suspended.  We  might 
derive  the  same  suggestion  from  the  similarly  degenerate  muscular 
fibres ;  in  which  we  may  often  find  the  fat  particles  arranged  in  the 
same  manner  as  the  proper  constituents  of  the  fibrils,  and  looking  as  if 
there  were  a  gradual  transformation  of  the  "  sarcous  elements"  into  the 
little  oily  particles,  which,  by  clustering,  and  then  by  fusion,  at  length 
compose  the  larger  oil-drops. 

We  gain  other  and  better  evidence  of  the  fatty  matter  being  derived 
from  chemical  changes  in  the  tissue  that  is  degenerate,  from  many  other 
sources.  Such  changes  are  exemplified  in  the  production  of  fatty  mat- 
ters during  the  spontaneous  decompositions  of  nitrogenous  substances. 
Many  instances*  of  this  are  known,  but  none  are  so  appropriate  as  the 
formation  of  adipocere  in  muscular  tissue.  Here,  as  Dr.  Quain  dis- 
covered, the  places  of  the  muscular  fibres,  bloodvessels,  and  nerves,  are 
occupied  by  fatty  matter,  which  could  not  have  existed  in  them  during 
life,  which  is  far  too  abundant  to  have  been  derived  from  changes  in 
the  fatty  matter  that  they  naturally  contain,  and  which,  in  confused 
crystals,  retains  their  natural  shape,  size,  and  arrangement.  And 
Dr.  Quain  has  completed  the  evidence  of  the  chemical  nature  of  these 
degenerative  changes,  by  an  artificial  imitation  of  them.  He  has  shown 
that  the  textures  of  hearts  (and  the  same  is  true  of  other  parts),  when 
placed  in  very  dilute  nitric  acid,  or  in  diluted  spirit,  pass  into  a  condi- 
tion exactly  resembling  that  of  the  fatty  degeneration  which  I  have 
been  desci'ibing.f  No  fact  could  be  more  apposite  to  prove  that  this 
form  of  degeneration  is  an  atrophy  ;  for  we  may  be  very  sure  that  when 
imitable  chemistry  prevails  in  a  part,  the  forces  of  life,  even  in  those  of 
morbid  life,  are  defective  or  suspended  in  it. 

The  whole  history  of  fatty  degenerations  concurs  to  prove  that  they 

*  Many  are  collected  by  Virchow,  in  his  Archiv,  B.  i,  p.  167  ;  and  others  by  Dr.  Quain, 
Med.  Chir.  Trans,  vol.  xxxiii,  p.  140,  et  seq.  The  facts  concerning  the  formation  of  sugar 
from  nitrogenous  compounds  in  the  liver  are  of  the  same  kind. 

■j"  Dr.  Quain  has  candidly  referred  to  many  previous  observers  by  whom  similar  changes 
were  recognized  ;  but  the  honor  of  the  full  proof,  and  of  the  right  use  of  it,  belongs  to  him- 
self alone.  Respecting  the  method  of  the  chemical  transformations  by  which  the  change  is 
accomplished,  the  best  essay  is,  I  think,  that  of  Virchow  (Archiv,  B.  i,  p.  152). 


FATTY    DEGENERATION.  93 

are  the  result  of  defect,  not  of  disease,  of  the  nutritive  process ;  and 
that  they  may  be  therefore  classed  with  the  atrophy  which  we  recognize 
in  merely  diminished  quantity  of  formation.  Let  me  point  out  the 
chief  features  of  this  history :  for  even  some  repetition  of  the  earlier 
part  of  the  lecture  will  be  justified  by  the  utility  of  assigning  their 
right  place  in  pathology  to  changes  of  which  (as  is  the  case  with  all 
these  degenerations)  we  are  every  year  gathering  new  and  very  impor- 
tant illustrations. 

I  have  said  that  the  types  or  standards  of  degenerations  are  the 
changes  naturally  ensuing  in  old  age.  Kow,  accumulations  of  fat, 
which  in  many  parts  assume  the  forms  of  the  fatty  degeneration  of 
tissues,  are  striking  characteristics  of  old  age,  and  especially -of  the 
commencement  of  senile  infirmities.  The  results  of  senile  atrophy  are 
not,  indeed,  the  same  in  all  persons :  rather,  you  find  among  old  people, 
and  you  might  almost  thus  arrange  them  into  two  classes,  the  lean  and, 
the  fat ;  and  these,  as  you  may  see  them  in  any  asylum  for  the  aged, 
impersonate  the  two  kinds  of  atrophy  I  have  spoken  of,  as  the  withering 
and  the  fatty  degenerations. 

Some  people,  as  they  grow  old,  seem  only  to  wither  and  dry  up  ; 
sharp-featured,  shrivelled,  spinous  old  folk,  yet  withal  wiry  and  tough, 
clinging  to  life,  and  letting  death  have  them,  as  it  were,  by  small  in- 
stalments slowly  paid.  Such  are  the  "lean  and  slippered  pantaloons;" 
and  their  "shrunk  shanks"  declare  the  pervading  atrophy. 

Others,  women  more  often  than  men,  as  old  and  as  ill-nourished  as 
these,  yet  make  a  far  different  appearance.  With  these  the  first  sign 
of  old  age  is  that  they  grow  fat ;  and  this  abides  with  them  till,  it  may 
be,  in  a  last  illness  sharper  than  old  age,  they  are  robbed  even  of  their 
fat.  These,  too,  when  old  age  sets  in,  become  pursy,  short-winded, 
pot-bellied,  pale  and  flabby;  their  skin  hangs,  not  in  wrinkles,  but  in 
rolls;  and  their  voice,  instead  of  rising  "towards  childish  treble," 
becomes  grufi"  and  husky.* 

These  classes  of  old  people,  I  repeat,  may  represent  the  two  chief 
forms  of  atrophy  ;  of  that  with  decrease,  and  that  with  fatty  or  other 
degeneration  of  tissues.  In  those  of  the  first  class  you  find  all  the 
tissues  healthy,  hardly  altered  from  the  time  of  vigor.  I  examined  the 
muscles  of  such  a  one ;  a  woman,  seventy-six  years  old,  very  lean, 
emaciated,  and  shrivelled.  The  fibres  were  rather  soft,  yet  nearly  as 
ruddy  and  as  strongly  marked  as  those  of  a  vigorous  man ;  her  skin, 
too,  was  tough  and  dry  ;  her  bones,  slender  indeed,  yet  hard  and  clean : 
her  defect  was  a  simple  defect  of  quantity,  and  of  moisture. 

*  Mr.  Barlow,  in  some  admirably  written  "  General  Observations  on  Fatty  Degeneration"' 
{Medical  Times  and  Gazette,  Isl-Ay  15,  18G2),  has  pointed  out  that  the  climacteric  disease, 
described  by  Sir  H.  Halford,  and  the  "  Decline  of  the  Vital  Powers  in  Old  Age,"'  described 
by  Dr.  Marshall  Hall,  are  probably,  in  great  measure,  dependent  on  such  fatty  degeneration 
as  these  persons  extremely  exemplify. 


94  FATTY    DEGENERATION. 

But  in  those  that  grow  fat  as  thej  grow  old,  you  find,  in  all  the 
tissues  alike,  bulk  with  imperfect  texture ;  there  is  fat  laid  between, 
and  even  within,  the  muscular  fibres  ;  fat  about  and  in  the  fibres  of  the 
heart,  in  the  kidneys,  and  all  the  vessels ;  their  bones  are  so  greasy 
that  no  art  can  clean  them :  and  they  are  apt  to  die  through  fatty 
degeneration  of  some  important  part,  such  as  the  heart,  the  minute 
cerebral  bloodvessels,  or  the  emphysematous  lungs.  The  defect  of  all 
these  tissues  is  the  defect  of  quality. 

Now,  I  do  not  pretend  to  account  for  this  great  difference  in  the 
concomitants  of  the  other  infirmities  of  old  age  in  different  people. 
The  explanation  probably  lies  far  among  the  mysteries  of  the  chemical 
physiology  of  nutrition,  of  the  formation  of  fat,  and  of  respiratory  ex- 
cretion ;  and  we  may  hope  to  'find  it  when  we  know  why,  out  of  the 
same  diet,  and  under  all  the  same  external  conditions,  one  class  of  men, 
even  in  health  and  vigor,  store  up  abundant  fat,  and  another  class 
excrete  the  elements  of  fat.  In  relation,  however,  to  the  present  sub- 
ject, the  main  point  is,  that  the  similarity  of  the  conditions  in  which 
they  occur  implies  similarity  in  the  essential  nature  of  the  two  changes, 
and  that  the  defective  quantity  and  the  defective  quality  of  the  tissues 
are  both  atrophies. 

The  same  conclusion  may  be  drawn  from  the  frequent  coincidence  of 
the  two  methods  of  degeneration  in  the  same  part.  In  the  limbs,  the 
most  common  form  of  atrophy  from  disease  is  manifested  in  diminution 
of  size,  together  with  increase  in  the  fatty  matter  combined  with  the 
muscles  and  bones.  Such  is  the  condition  usually  displayed  by  the 
bones  and  muscles  of  paralyzed  limbs ;  in  the  majority  of  atrophied 
stumps  after  amputation ;  and  in  many  other  similar  cases. 

In  like  manner,  the  fatty  degeneration  of  a  part  is  commonly  seen  as 
the  consequence  of  the  very  causes  which,  in  other  instances,  give  rise 
to  simple  wasting  or  emaciation  of  the  same  part.  Thus,  when  the 
function  of  a  -part  is  abrogated,  from  whatever  cause,  the  part  may  in 
one  person  shrink,  in  another  degenerate  into  fat.  The  emaciation  of 
a  paralyzed  limb  is  a  familiar  object :  but  in  some  cases  the  muscles  of 
paralyzed  limbs  are  hardly  reduced  in  size,  but  are  all  transformed  into 
fat.  In  the  College  Museum  there  is  a  pancreas,  with  a  cancerous 
tumor  pressing  on  its  duct,  and  all  behind  the  part  obliterated  is 
degenerated  into  fat ;  and  in  the  Museum  of  St.  Bartholomew's  there  is 
also  a  pancreas,  the  duct  of  which  was  obliterated  ;  but  in  this,  the  part 
behind  the  obstruction  is  simply  shrivelled,  dry,  hard,  and  scarcely 
lobulated.  So,  too,  among  the  bones  atrophied  in  different  bed-ridden 
persons,  some  are  exceedingly  light,  small,  and  dry :  others  are  not 
small,  but  very  greasy,  full  of  fatty  matter.  Either  of  these  results 
also,  or  the  two  mingled  in  various  proportions,  may  result  from  de- 
fective supply  of  blood ;  as  in  the  cases  of  atrophy  of  parts  of  bones 
after  fractures,  as  described  by  Mr.  Curling,  to  which  I  shall  have 
again  to  refer.     So  that  from  these,  and  from  many  other  cases  here- 


FATTY    DEGENERATION.  95 

after  to  be  mentioned,  Ave  may  say  generally,  that  nearly  all  the 
ordinary  causes  of  atrophy  may  produce,  in  any  part,  in  one  case  re- 
duction of  size,  in  another  fatty  degeneration,  in  another  a  concurrence 
of  the  two. 

Much  yet  remains  to  be  said  of  this  important  change  :  but  it  will  be 
more  appropriate  to  the  next  and  other  lectures,  in  which  I  shall 
describe  the  fatty  degenerations  of  several  parts,  and  of  the  products 
of  inflammation  and  other  diseases,  as  well  as  that  remarkable  form  of 
the  degeneration  which  ensues,  with  the  rapidity  of  an  acute  disease, 
in  the  proper  textures  of  some  inflamed  parts.  '  It  seems  only  necessary, 
in  conclusion,  to  state  that  there  appears  no  necessary,  or  even  frequent, 
connection  between  the  fatty  degeneration  of  any  organ  in  particular, 
and  that  general  tendency  to  the  formation  of  fat  which  constitutes 
obesity.  No  doubt,  a  person,  especially  an  elderly  one,  who  has  a 
natural  tendency,  even  when  in  health,  to  become  corpulent,  will, 
cceteris  paribus,  be  more  likely  to  have  fatty  degeneration,  than  to  have 
a  wasting  atrophy,  in  any  organ  which  may  fall  into  the  conditions  in 
which  these  changes  originate.  And,  as  a  general  rule,  spirit-drinking, 
and  the  excessive  use  of  hydro-carbonaceous  articles  of  food,  while 
favoring  a  general  formation  of  fat,  are  apt  to  give  rise  to  special  fatty 
degeneration  in  the  liver,  or  some  other  organ.  Yet,  on  the  other 
hand,  one  commonly  finds  the  proper  elements  of  the  tissues  —  the 
heart,  the  liver,  and  the  rest  —  quite  healthy  in  men  who  are  very  cor- 
pulent. The  muscular  fibres  of  the  heart,  or  of  the  voluntary  muscles, 
may  be  imbedded  in  adipose  tissue,  and  yet  may  be  themselves  free 
from  the  least  degeneration.  So,  also,  the  hepatic  cells  may  be  nearly 
free  from  fat  within,  though  there  be  much  oil  around  them.  Fat 
accumulated  in  tissue  round  the  elements  of  a  part  is  a  very  diff"erent, 
probably  an  essentially  different,  thing  from  fat  within  them ;  the  one 
is  compatible  with  perfect  strength,  the  other  is  always  a  sign  of  loss 
of  power.  In  the  muscles  of  some  fish,  such  as  the  eel,  it  is  hard  to 
get  a  clear  sight  of  the  fibres,  the  oily  matter  around  them  is  so  abun- 
dant :  but  the  fibres  are  peculiarly  strong,  and,  in  their  own  texture, 
make  a  striking  contrast  with  the  fibres  of  a  degenerate  muscle,  in 
which  the  fat  is,  in  great  part,  within. 

The  same  essential  distinction  between  general  and  local  fat-forma- 
tion, though  they  may  often  coincide,  is  shown  in  the  fact  that  the  local 
formation  very  often  happens  in  those  whose  general  condition  is  that 
of  emaciation,  as  in  the  phthisical  and  chlorotic. 

On  the  whole,  therefore,  we  must  conclude  that  something  much 
more  than  a  general  tendency  to  form  fat,  or  a  general  excess  of  fat 
in  the  blood,  is  necessary  to  produce  a  local  fatty  degeneration.  The 
general  conditions  are  favorable,  but  not  essential,  to  this  form  of 
atrophy. 


96  ATROPHY. 

LECTURE  VL 

ATROPHY. 

The  last  lecture  was  chiefly  occupied  with  a  general  account  of 
those  changes  of  texture  which  are  to  be  regarded  as  atrophies ;  and 
now,  having  pointed  out  what  affections  may  be  classed  under  this 
term,  the  whole  subject  may  be  more  largely  illustrated  by  particular 
examples. 

First,  as  to  the  conditions  in  which  atrophy,  whether  with  decrease 
or  with  degeneration,  may  ensue.  Many  of  them  may  be  most  easily 
explained  as  the  very  contraries  of  the  conditions  in  which  hypertrophy 
originates.  Thus,  as  we  have  seen  that  when  a  part  is,  within  certain 
limits,  over-exercised,  it  is  over-nourished ;  so,  if  a  part  be  used  less 
than  is  proper,  it  suffers  atrophy.  For  instance,  in  the  Museum  of 
St.  Bartlaolomew's  (Ser.  12 ;  57)  is  the  heart  of  a  man,  fifty  years  old, 
who  died  with  cancer  of  the  stomach  in  extreme  emaciation.  It  is 
extremely  small,  and  weighed  only  five  ounces  four  drachms ;  whereas, 
according  to  the  estimates  of  Dr.  Clendinning,  in  a  healthy  man  of  the 
same  age  the  heart  weighs  upwards  of  nine  ounces.  But,  small  as  it  is, 
this  heart  was  adapted  to  the  work  it  had  to  do ;  and  in  this  adaptation 
we  have  the  purpose  of  its  atrophy.  For,  because  of  his  cancer,  the 
man  had  less  blood,  and  needed  less  force  of  the  heart  to  propel  it :  so 
that,  in  direct  opposition  to  what  I  described  as  the  course  of  events  in 
hypertrophy,  here,  as  the  quantity  of  blood  diminished,  and  the  waste 
of  the  heart  by  exercise  in  propelling  it  diminished,  so  the  repair  of  the 
waste  diminished  somewhat  more  than  the  waste  itself  did :  and  the 
heart,  though  less  wasted,  became  smaller,  till  it  was  only  large  enough 
for  the  propulsion  of  the  scanty  supply  of  blood. 

The  same  may  be  said  of  a  heart  of  which  there  is  a  drawing  in  the 
same  Museum.  It  was  taken  from  a  woman  twenty-two  years  old,  who 
died  with  diabetes.  It  weighed  only  five  ounces  ;  yet,  doubtless,  it  was 
enough  for  her  impoverished  supply  of  blood. 

It  would  be  superfluous  to  describe  many  instances  of  atrophy 
through  defective  exercise,  or  abrogated  function  of  parts.  The  wasted 
and  degenerate  limbs  of  the  bed-ridden,  the  shrunken  brains  of  the 
aged  and  the  imbecile,  the  withered  ovaries  and  uteri  of  many  barren 
women,  are  good  examples  of  defective  nutrition  adapted  to  defective 
exercise  of  function :  and  so  are  the  atrophied  distal  parts  of  nerves 
whose  trunks  have  been  divided,  and  the  atrophied  columns  of  the 
spinal  cord  that  correspond  with  inactive  portions  of  the  brain.  The 
rapid  degeneration  and  removal  of  the  tissue  of  the  uterus  after  par- 
turition, and  the  rapid  disappearances  of  temporary  organs  of  various 
kinds,  are  as  striking  examples  of  atrophy  following  the  abrogation  or 
completion  of  ofiice.     To  some  of  these  examples  I  shall  again  refer. 


ATROPHY.  97 

It  is  in  similar  contrast  witli  the  history  of  increased  growths,  that, 
as  an  excess  of  the  constituents  of  which  a  tissue  may  form  itself  pro- 
duces hypertrophy  of  that  tissue,  so  may  defect  of  those  constituents 
produce  atrophy.  Thus,  the  quantity  of  adipose  tissue  diminishes  even 
below  what  is  natural  to  the  several  parts,  as  often  as  the  fat-making 
constituents  are  deficient  in  the  food,  and  therefore  in  the  hlood.  So, 
the  formation  of  bones  is  defective  during  deficiency  of  the  supply  of 
bone-earths  ;  the  mammary  glands  waste  when  the  materials  for  the 
formation  of  milk  are  imperfectly  supplied ;  and  the  whole  body  wastes 
in  general  defect  or  poverty  of  blood. 

Again,  as  I  showed  instances  in  which  the  increased  flow  of  healthy 
blood  through  a  part  produced  hypertrophy,  so  are  there  more  numer- 
ous examples  of  merely  defective  nutrition  in  consequence  of  a  dimin- 
ished supply  of  blood.  Some  of  the  most  striking  of  these  were  first 
described  by  Mr.  Curling,*  in  cases  of  fractured  femora  and  other 
bones,  showing  atrophy  of  that  portion  which,  by  the  fracture,  was  cut 
off"  from  the  supply  of  blood  through  the  great  nutritive  or  medullary 
artery.  The  consequence  of  the  withdrawal  of  so  much  of  the  blood 
from  the  upper  or  lower  fragment,  according  to  the  position  of  the  frac- 
ture, is  not  death ;  for  the  anastomosis  between  the  vessels  of  the  wall 
and  those  of  the  medullary  tissue  of  the  bone  is  enough  to  support  life, 
though  not  enough  to  support  vigorous  nutrition  ;  but  the  frequent  con- 
sequence of  the  fracture  is  an  atrophy  of  the  part  thus  deprived  of  a 
portion  of  its  ready  supply  of  blood. 

Similar  instances  are  seen  in  the  decrease  or  degeneration  of  portions 
of  hearts  when  single  branches  of  a  coronary  artery  are  obstructed  ;f  in 
the  wasting  of  a  portion  of  kidney  when  a  branch  of  a  renal  artery  is 
closed  ;J  and  in  local  softening  of  the  brain,  with  obliteration  of  single 
cerebral  arteries. § 

In  all  these  instances  we  see  that  conditions  contrary  to  those  giving 
rise  to  hypertrophy  produce  atrophy.  But  there  are  many  other  con- 
ditions from  which  atrophy  in  a  part  may  ensue  :  defects  in  quantity, 
or  in  the  constitution  of  the  blood  ;  defective  or  disturbed  nervous  influ- 
ence, as  through  excessive  mental  exertion  ;  the  disturbances  of  disease 
or  injury,  as  in  inflammation,  specific  morbid  infiltrations,  &c.  In 
short,  whatever  interferes  with  or  interrupts  any  of  those  conditions 
which  I  enumerated  as  essential  to  healthy  nutrition,  may  give  rise  to 
atrophy,  either  general  or  local.  The  clinical  history  of  the  fatty  de- 
generation of  the  heart,  so  largely  illustrated  by  Dr.  Ormerod||  and 
Dr.  Quain,^  may  best  prove  how  multiform  are  the  events  from  which 
the  atrophy  of  a  single  organ  may  arise. 

*  Medico-Chirnrg.  Trans,  vol.   xx. 

f  Quain,  Medico-Chir.  Trans,  xxxiii,  p.  148  ;  Virchow,  Archiv,  iv,  p.  387. 

X  Simon,  Lectures  on  Pathology,  p.  94.     §  Kirkes,  Med.  Chir.  Trans,  vol.  xxxv. 

II  Medical  Gazette,  1849.  IT  Medico-Chirurgical  Trans,  vol.  xxxiii,  1850. 


98  '       ATROPHY    OF 

But  besides  all  tlie  instances  in  whicli  atrophy  of  a  part  may  arise  as 
a  secondary  process,  there  are  others  in  which  we  are  so  unable  to  trace 
its  precedents,  that  we  are  tempted  to  speak  of  it  as  primary,  or  spon- 
taneous, in  the  same  sense  as  we  might  so  call  the  natural  wasting  of 
the  Wolffian  bodies,  the  thymus,  and  other  temporary  organs.  It  is  as 
if  an  atrophy  of  old  age,  instead  of  affecting  all  parts  simultaneously, 
took  place  prematurely  in  one. 

Whatever  the  true  explanation  may  be,  most  of  the  parts  of  th«  body 
appear  to  be  subject  to  this  seemingly  spontaneous  atrophy  ;  and  it 
generally  manifests  itself  in  some  form  of  degeneration.  Its  most  fre- 
quent seats  are  the  heart  and  arteries,  the  bones,  muscles,*  liver,  and 
kidneys  ;  but  it  occurs  also  in  the  pancreas  and  the  salivary  glands, 
in  the  testicle,  and  even  in  the  blood.  It  is  yet  more  frequent  in  mor- 
bid products,  as  in  the  exudations  of  inflammation,  and  tumors  of  every 
kind. 

The  contrast  between  hypertrophy  and  atrophy  is,  thus,  nearly  as 
great  in  the  number,  as  in  the  kind,  of  the  conditions  in  which  they  may 
severally  arise.  And,  once  more,  we  may  contrast  them  in  regard  to 
the  mode  in  which  the  vessels  and  nerves  adapt  themselves.  As  a  part 
becomes  atrophied,  its  bloodvessels  and  its  nerves  are  consequently  and 
proportionally  changed.  In  atrophy  of  the  eye,  the  optic  nerve  and 
artery  diminish  ;  and,  in  a  case  of  fatty  degeneration  of  the  adductor 
muscles  of  the  thigh,  in  consequence  of  disease  of  the  hip-joint,  I  found 
corresponding  atrophy  of  their  nerves.     The  atrophy  of  the   nerves 

*  The  publication  by  Dr.  Meryon,  a  few  years  ago  (Trans.  Med.  Chir.  Soc.  vol.  35)  of  a 
remarkable  series  of  cases  in  which  fatty  degeneration  of  the  voluntary  muscles  appeared 
to  arise  as  a  primary,  or  spontaneous  affection,  has  prominently  directed  the  attention  of  pa- 
thologists in  this  country  to  the  subject.  It  has  also  been  carefully  investigated  on  the  Con- 
tinent by  Cruveilhier,  Duchenne,  Aran,  Oppeuheimer,  Wachsmuth,  and  others.  The  best 
historical  and  analytical  account  of  the  disease  which  has  yet  appeared  is  by  Dr.  Roberts, 
in  his  "  Essay  on  Wasting  Palsy,"  1858.  He  argues  for  the  spontaneous  origin  of  the  de- 
generation. But  there  are  not  wanting  pathologists  who  look  for  the  cause  of  this  muscular 
atrophy,  not  in  the  muscles  themselves,  but  in  the  centres  from  which  the  nerves  that  sup- 
ply them  spring.  A  case  has  just  been  published  by  Dr.  Radcliffe  and  Mr.  Lockhart  Clarke 
(Med.  Chir.  Rev.  July,  1862),  which  confirms,  at  least  in  this  particular  instance,  this  view 
of  the  cause  of  the  lesion.  The  patient,  a  male  set.  forty,  was  greatly  emaciated.  The 
relics  of  his  muscles  were  tense  and  rigid,  and  altogether  disobedient  to  the  will.  The  cord, 
on  being  examined  microscopically  by  Mr.  Clarke,  exhibited  a  remarkable  change  in  the 
nerve-cells,  which  were  reduced  in  number,  altered  in  shape,  and  singularly  atrophied. 
The  columns  of  the  cord  were  also  atrophied  or  degenerated.  In  another  case,  recorded 
by  Dr.  W.  T.  Gairdner  in  Beale's  Archives,  October,  1861,  in  which  the  cord  was  examined 
by  Mr.  Clarke,  atrophy  of  the  muscles  of  the  upper  limbs  was  accompanied  by  lesion  of  the 
cervical  part  of  the  cord;  and  in  a  third  case,  by  Dr.  Gull  (Guy's  Hospital  Reports,  vol.  viii, 
p.  244,  1862),  in  which  there  was  progressive  atrophy  of  the  muscles  of  the  hands,  the 
post  mortem  examination  revealed  a  considerable  dilatation  of  the  ventricle  of  the  cervical 
part  of  the  cord,  and  atrophy  of  the  gray  matter. 

More  extended  observations  on  these  cases  of  wasting  palsy  may  perhaps  teach  us  that 
in  looking  for  the  causes  of  muscular  atrophy  we  may  have  to  distinguish  two  distinct  sets 
of  cases,  one  in  which  degeneration  of  the  muscles  arises  as  a  primary  affection,  the  other 
in  which  it  results  from  a  lesion  of  the  nervous  centres  from  which  the  nerves  that  supply 
the  muscles  arise. 


VOLUNTARY     MUSCLES.  99 

must  have  been,  in  this  case,  secondary :  the  course  of  events  being, 
inaction  of  the  muscles  in  consequence  of  the  disease  of  the  joint  ;  then, 
atrophy  of  them  in  consequence  of  their  inaction  ;  and,  finally,  atrophy 
of  the  nerves  following  that  of  the  muscles. 

From  these  general  considerations  I  proceed  to  speak  particularly  of 
Atrophy,  as  it  manifests  itself  in  some  of  the  principal  organs  and  tis- 
sues of  the  body  ; — and  first  of  the  Atrophy  of  Muscles. 

The  affection  has  been  well  studied  in  all  the  three  forms  of  muscu- 
lar tissue  ;  namely,  in  the  voluntary  muscles,  in  the  heart,  and  in  the 
organic  or  smooth-fibred  muscles  ;  and  I  will  describe  it  in  each  of  these 
in  order. 

The  voluntary  muscles  exhibit,  in  different  conditions,  both  the  chief 
forms  of  atrophy ;  that,  namely,  with  decrease  or  wasting,  and  that 
with  fatty  degeneration. 

In  a  wasted  muscle,  such  as  one  sees,  for  example,  in  the  limbs  of 
those  who  are  only  emaciated,  the  fibres  may  appear  almost  perfectly 
healthy :  they  are  rather  paler,  indeed,  and  softer,  and  more  disposed 
to  be  tortuous,  than  in  the  natural  state  ;  for  muscles  are  commonly 
withered  when  they  are  thus  reduced  in  size  ;  yet  their  transverse  striae, 
and  all  their  other  characteristic  features,  are  well  marked. 

In  the  state  of  fatty  degeneration,  the  whole  of  a  voluntary  muscle 
may  appear  pale,  bleached,  or  of  some  yellowish  or  tawny  hue,  soft  and 
easily  torn.  But  a  more  frequent  appearance  is  that  in  which  fasciculi 
in  the  healthy  state,  and  others  in  various  degrees  of  degeneration,  lie 
in  parallel  bands,  and  give  the  whole  muscle  a  streaky  appearance,  with 
various  hues,  intermediate  between  the  ruddiness  of  healthy  flesh,  and 
the  dull,  pale,  tawny-yellow,  or  yellowish-white,  of  the  complete  de- 
generation. In  such  a  .case  (and  this  may  appear  remarkable)  healthy 
primitive  fibres  may  lie  among  those  that  are  degenerated.  Of  the  lat- 
ter, some,  in  place  of  the  transverse  striae,  present  dark  very  minute 
dots  arranged  in  transverse  lines  ;  in  others,  the  whole  fibre  has  a  dim, 
pale,  granular  aspect,  with  no  definite  arrangement  of  the  granules  ;  in 
others,  little  oil-globules  adhere  to  the  interior  of  the  sarcolemma  ;  and 
in  others,  such  globules  are  collected  more  abundantly,  and  to  the  pro- 
portionally greater  exclusion  of  the  proper  constituents  of  the  fibres  : 
but  the  characters  of  fatty  degeneration  are  rarely,  if  ever,  so  well 
marked  in  the  fibres  of  voluntary  muscles  as  in  those  of  the  heart.* 

In  the  examination  of  different  examples  of  fatty  degeneration  of  the 
voluntary  muscles,  you  may  find  much  diversity  in  the  tissue  between 

*  There  has  been  some  speculation  amongst  pathologists  respecting  the  part  of  the  fibre 
in  which  the  fatty  change  commences.  Some  have  supposed  that  the  fibrillEE,  or  sarcous 
elements,  become  gradually  converted  into  fat-granules.  The  opinion,  however,  appears 
to  be  now  gaining  ground  that  the  disposition  of  fatty  particles  takes  place,  in  the  first  in- 
stance, between  the  fibrillse,  around  the  nuclei,  or  cells,  within  the  fibre  itself  See  espe- 
cially, Bottcher,  in  Virchow's  Archiv,  13th  vol.  p.  227,  1858,  and  C.  0.  Weber  Die  En- 
twicklung  des  Eiters.  Virchow's  Archiv,  15th  vol. 


100  ATROPHY    OF 

the  fibres  and  fasciculi.  In  some  instances,  the  interspaces  between 
the  fasciculi  are  filled  with  connective  tissue,  both  more  abundant  and 
tougher  than  that  in  healthy  muscle  ;  so  that  it  may  be  hard  to  dissect 
the  fibres  for  the  microscope.  With  this  there  may  be  no  unusual 
quantity  of  fat ;  but,  in  other  cases,  the  quantity  of  fat  between  the 
fibres  is  very  great,  and  the  fibres  themselves  may  seem  empty,  or 
wasted,  as  if  overwhelmed  by  the  fat  accumulating  around  them.  In 
such  a  case,  when  the  accumulating  fat  has  coalesced  with  that  which 
before  surrounded  the  whole  muscle,  it  may  be  difficult  to  find  where 
the  muscle  was  ;  for  the  whole  of  what  belonged  to  it,  after  its  degenera- 
tion, may  be  gone,  and  in  its  place  there  may  remain  only  an  obscure 
trace,  if  any,  of  fibrous  arrangement,  dependent  on  the  position  of  the 
principal  partitions  of  the  new  fatty  tissue. 

I  cannot  yet  speak  positively  in  explanation  of  this  diversity  in  the 
state  of  parts  between  the  fibres.  But,  I  think,  the  increase  and  tough- 
ness of  the  connective  tissue  (when  it  is  not  the  product  of  organized 
inflammatory  deposit)  exist  only  in  atrophied  muscles  which  have  had 
to  resist  stretching,  after  the  manner  of  ligaments;  as,  for  example, 
when  their  antagonists  are  not  as  powerless  as  themselves.  And  the 
increase  of  fat  seems  to  be  found  only  when  a  muscle  has  been  very  long 
atrophied,  and  has  remained  completely  at  rest ;  then,  the  fibres  them- 
selves, after  degenerating,  may  be  removed,  and  give  place  to  a  forma- 
tion of  common  adipose  tissue,  which  collects  in  every  part  that  they 
are  leaving,  just  as  it  does  about  shrinking  kidneys,  some  cancers  of 
the  breast,  old  diseased  joints,  and  other  parts  similarly  circumstanced. 

In  either  case,  we  must  distinguish  between  these  formations  of  fat 
outside,  and  those  within,  the  fibres  ;  the  former  are  in  no  necessary 
connection  with  the  proper  atrophy  of  the  fibres,  but  generally  appear 
subsequent  to  it ;  and  when  they  attain  their  highest  degree,  they  are 
not  to  be  regarded  as  degenerations  of  the  muscular  tissue  ;  for  they 
are  not,  in  any  sense,  formed  out  of  it,  though  they  occupy  the  place 
from  which  it  was  removed.  This  external,  or  interstitial,  formation 
of  fat  possesses  the  structure  of  adipose  tissue,  for  the  fat  is  contained 
in  cells,  which  present  the  well-known  characters  of  fat-cells.  These 
cells  are  developed  in  the  connective  tissue,  which  lies  between  the 
fibres. 

The  condition  in  which  atrophy  of  the  voluntary  muscles  most  com- 
monly ensues  is  inaction.  Whenever  muscles  lie  long  inactive,  they 
either  waste  or  degenerate :  and  this,  whether  the  inactivity  depend  on 
paralysis  through  afi"ection  of  the  nervous  centres,  or  fibres,  or  fixity  of 
the  parts  they  should  move,  or  on  any  other  cause.  The  degenerative 
process  may  be  so  rapid  that,  in  a  fortnight,  muscles  paralyzed  in 
hemiplegia  may  present  a  manifest  change  of  color  :  but  it  is  com- 
monly a  much  slower  process. 

The  course  of  events  in  these  cases  appears  to  be,  that  the  want  of 
exercise  of  a  muscle,  whether  paralyzed  or  fixed  at  its  ends,  makes  its 


VOLUNTARY    MUSCLES.  101 

due  nutrition  impossible  ;  and  the  atrophy  thus  brought  about  is  the 
cause  of  loss  of  imtability  of  the  muscle,  i.  e.  of  loss  of  its  capacity  for 
contracting.  For  the  experiments  of  Dr.  John  Reid*  show  that  loss  of 
contractile  power  in  a  paralyzed  muscle  is  due,  directly,  to  its  imperfect 
nutrition,  and  only  indirectly  to  the  loss  of  connection  with  the  nervous 
centres.  When  he  divided  the  nerves  of  a  frog's  hind  legs,  and  left  one 
limb  inactive,  but  gave  the  muscles  of  the  other  frequent  exercise,  by 
galvanizing  the  lower  end  of  its  divided  nerve,  he  found  (to  state  the 
case  very  briefly)  that  at  the  end  of  two  months  the  exercised  muscles 
retained  their  weight  and  texture,  and  their  capacity  of  contraction  ; 
while  the  inactive  ones  (though  their  irritability,  it  might  be  said,  had 
not  been  exhausted  by  exercise)  had  lost  half  their  bulk,  were  degene- 
rate in  texture,  and  had  also  lost  some  of  their  power  of  contracting. 
In  other  cases,  too,  he  found  the  loss  of  proper  texture  always  ensuing  in 
the  inactive  state,  before  the  power  of  contraction  was  lost. 

It  is  doubtless  the  same  in  man.  A  muscle  which,  by  no  fault  of  its 
OAvn,  but  through  circumstances  external  to  itself,  has  been  prevented 
from  acting,  soon  becomes  incapable  of  acting  even  when  the  external 
obstacles  to  action  are  removed.  Hence  we  may  deduce  a  rule  which 
ought  to  be  acted  on  in  practice.  When  a  person  has  had  hemiplegia, 
one  commonly  sees  that  long  after  the  brain  has,  to  all  appearance,  re- 
covered its  power,  or  even  through  all  the  rest  of  life,  the  paralyzed 
limbs  remain  incapable  of  action,  and  as  motionless  as  at  the  first  at- 
tack. Now,  it  is  not  likely  that  this  abiding  paralysis  is  the  conse- 
quence of  any  continuing  disease  of  the  brain  ;  rather,  we  must  ascribe 
it  to  the  imperfect  condition  into  which  the  muscles  and  nerve-fibres 
have  fallen  during  their  inaction.  So  long  as  the  state  of  the  brain 
makes  voluntary  action  impossible,  the  cord,  nerves,  and  muscles,  are 
suff"ering  atrophy  ;  then,  when  the  brain  recovers,  they  are  not  in  a 
state  to  obey  its  impulses,  because  they  are  degenerate  ;  and  thus,  their 
inaction  continuing,  they  degenerate  more  and  more,  and  all  remedy 
becomes  impossible.  If  this  be  true,  Dr.  Reid's  experiments 'suggest 
the  remedy.  When  muscles  are  paralyzed  through  affection  of  the  ner- 
vous system,  we  ought  to  give  them  artificial  exercise  :  they  should  be 
often  put  in  action  by  electricity  or  otherwise  ;  their  action,  though 
thus  artificial,  will  insure  their  nutrition  ;  and  then,  when  the  nervous 
system  recovers,  they  may  be  in  a  condition  ready  to  act  with  it. 

You  will  find  this  suggestion  ingeniously  supported  by  my  friend  Mr. 
W.  F.  Barlow,  in  a  paper  published  by  him  in  the  "  Lancet."  In  one 
case,  in  which  I  could  act  upon  it,  the  result  was  encouraging.  A  little 
girl,  about  eight  years  old,  had  angular  curvature  and  complete  loss  of 
voluntary  movement  in  the  lower  extremities.  This  had  existed  some 
weeks,  but  as  I  found  she  had  reflex  movements,  the  legs  twitching  in 
a  very  disorderly  way  as  often  as  the  soles  were  touched,  I  advised  that 

*  Edin.  Monthly  Journ.  of  Med.  Science,  May,  1841.  See  also,  M.  Brown-Sfequard,  in 
the  Gaz.  Medicale,  No.  9,  1850. 


102  ATROPHY    OF 

the  limbs  should  be  put  in  active  exercise,  for  about  an  hour  two  or 
three  times  a  day,  by  tickling  the  feet,  or  in  some  similar  way.  The 
result  was,  that  when,  several  weeks  afterwards,  the  spinal  cord  re- 
covered, and  she  could  again  direct  the  effort  of  the  will  to  the  lower 
limbs,  the  recovery  of  strength  was  speedy  and  complete ;  more  so,  I 
think,  than  if,  in  the  paralyzed  condition,  the  muscles  and  nerves  had 
been  left  to  the  progress  of  the  atrophy.  A  similar  paralysis,  about  two 
years  later,  occurred  again,  and  was  similarly  recovered  from. 

The  hindered  action  of  muscles,  though  the  most  frequent,  is  not  the 
only  condition  from  which  their  atrophy  may  ensue.  They  waste, 
together  with  all  the  rest  of  the  body,  in  most  emaciating  diseases ;  as, 
for  example,  in  phthisis  :  and  they  may  degenerate  into  fat,  in  concert 
with  other  tissues,  in  a  generally  defective  nutrition. 

But,  besides  the  general  atrophies  of  muscles,  a  similar  affection  oc- 
curs sometimes  as  a  primary  or  spontaneous  affection  of  one  or  more 
muscles.  We  find  sometimes  one  of  the  muscles  of  an  extremity,  or  of 
the  back,  thoroughly  atrophied,  while  the  others  are  healthy ;  and  no 
account  can  be  given  of  its  failure :  or  we  may  even  have  in  the  same 
muscle  limited  patches  of  degenerated  structure  separated  by  inter- 
vening healthy  tissue.  Thus,  it  is  not  very  unfrequent  to  find  a  portion 
of  the  lower  and  posterior  part  of  the  recti  abdominis  muscles  in  a  state 
of  fatty  degeneration,  and  the  same  may  be  occasionally  seen  in  portions 
of  the  deep  muscles  of  the  back. 

Rokitansky*  briefly  refers  to  a  spontaneous  fatty  degeneration  of 
the  muscles  of  the  calf  attended  with  extreme  pain  :  Mr.  Mayof  has 
recorded  two  cases  of  apparently  spontaneous  atrophy  of  the  muscles  of 
the  shoulder,  in  which,  in  a  few  weeks  after  severe  pain,  but  no  other 
sign  of  acute  inflammation,  all  the  muscles  about  the  shoulder  became 
simply,  but  exceedingly,  atrophied ;  and  still  more  recently.  Dr.  Bauer| 
has  related  a  case  in  which  pain  in,  and  contraction  and  wasting  of,  the 
muscles  of  the  calf  followed  a  stab  in  the  back  near  the  spine. 

We  name  these  spontaneous  atrophies,  and  it  may  be  that  the  defec- 
tive nutrition  is  the  first  event  in  the  abnormal  chain ;  but,  I  think,  we 
shall  hereafter  find  that,  in  most  of  them,  the  degeneration  is  a  part  of 
some  inflammatory  process ;  for,  as  I  shall  have  to  describe  in  future 
lectures,  there  is  no  tissue  in  which  it  is  more  evident  than  in  the 
muscles,  that  a  degeneration  of  the  proper  elements  of  an  inflamed  part 
is  associated  with  the  more  obvious  efi"ects  of  inflammation.  § 

Atrophy  of  the  muscular  substance  of  the  heart  may,  like  that  of 

*  Pathol.  Anat.  B.  2,  S.  348.  f  Outlines  of  Human  Pathology,  1836  ;  p.  117. 

X   On  Hip  Diseases,  New  York,  1859. 

§  Virchow  has  recorded  in  his  Archiv,  vol.  xiii,  p.  2G6,  1858,  two  cases  of  pericarditis, 
in  which  there  was  fatty  degeneration  of  the  muscular  fibres  of  the  heart.  The  degenera- 
tion was  much  more  strongly  marked  in  those  fibres  which  were  nearest  the  outer  surface, 
and  gradually  diminished  in  the  deeper  parts.  From  these  circumstances  he  is  of  opinion 
that  in  these  cases  the  fafty  metamorphosis  was  a  consequence  of  the  pericarditis. 


THE    HEART.  103 

which  I  have  just  been  speaking,  appear  in  either  wasting  or  degenera- 
tion, or  in  a  combination  of  the  two.  Of  the  former  I  mentioned 
examples  in  the  beginning  of  the  lecture,  in  the  heart  of  a  cancerous 
man,  fifty  years  old,  which  weighed  only  five  ounces  four  drachms ;  and 
that  of  a  diabetic  woman,  twenty-two  years  old,  which  weighed  only 
five  ounces  one  drachm.  Both  these  had  deviated  from  the  general 
rule  of  enlargement  of  the  heart  with  advancing  years,  in  adaptation 
to  the  diminished  quantity  of  blood,  and  the  general  diminution  of  the 
body. 

In  these  cases  there  is  a  uniform  decrease  of  the  heart :  its  cavities 
become  small,  and  its  walls  proportionally  thin;  and  the  fat  on  its  ex- 
terior diminishes,  or  is  changed  into  a  succulent,  oedematous  tissue.  In 
other  instances  the  cavities  are  dilated,  without  proportionate  thicken- 
ing, or,  it  may  be,  even  with  thinning  of  their  walls.  This,  probably, 
occurs  chiefly  in  cases  of  such  increased  obstacles  to  the  circulation  as 
might,  in  other  persons,  or  in  other  conditions,  engender  hypertrophy 
of  the  heart.  Or,  the  dilatation  may  be  the  consequence  of  wasting  in 
a  heart  that  was  once  large  and  strong. 

But,  an  atrophy  of  the  heart  much  more  important  than  any  of  these, 
is  that  which  consists  in  fatty  degeneration. 

Extreme  instances  of  fatty  degeneration  of  the  heart  have  been  long 
known.  The  whole,  or  the  greater  part  of  the  heart,  in  such  cases,  may 
seem  reduced  to  fat ;  the  degenerate  tissue  having  coalesced  with  that 
which  lies  on  its  surface,  and  the  degeneration  being  accompanied  by 
thinning  and  softening  of  the  walls. 

In  like  manner,  the  cases  have  been  well  known  and  described  for  ^ 
which  Dr.  Quain  proposes  the  name  of  "fatty  growth,"  to  distinguish 
them  from  the  "fatty  degenerations"  of  the  heart.  In  these,  the 
adipose  tissue  accumulates  in  unusual  quantity  on  those  parts  of  the 
exterior  of  the  heart  in  which  it  naturally  exists,  and  is  found,  though 
often  emaciated  and  very  soft,  even  in  the  thinnest  people,  viz.,  along 
its  transverse  furrows,  the  furrows  in  which  the  coronary  vessels  run, 
and  others.  From  these  positions,  the  fat  dipping  more  and  more 
deeply  may  nearly  displace  the  fibres,  and  may  lead  to  a  secondary 
degeneration  of  them  ;  but,  commonly,  the  heart's  fibres  are  themselves 
healthy,  even  when  they  lie  completely  imbedded  in  the  overgrown  fat. 

But  these  conditions,  and  their  combinations,  are  too  well  known  to 
need  that  I  should  describe  them,  or  refer  particularly  to  any  speci- 
mens of  them,  except  to  a  sheep's  heart,  which  is  in  the  College 
Museum  (No.  1529),  and  which  shows,  in  an  extreme  degree,  a  method 
of  the  growth  of  fat  which  is  rarely  imitated,  in  even  a  trivial  measure, 
in  the  human  subject.  It  exhibits  a  great  accumulation  of  fat  on  its 
surface,  and  its  walls  are  thin;  but  the  greater  parts  of  the  cavities  of 
the  ventricles  and  of  the  left  auricle  are  occupied  by  large  lobulated 
growths  of  suet-like  fat.  The  weight  of  the  fat  here  added  to  the  heart 
is  25  ounces,  and  it  is  said  that  there  was  also  a  large  accumulation  of 


104  ATROPHY    OP 

fat  about  the  kidneys.  But  no  other  history  of  the  ease  is  extant  than 
that  the  sheep  was  inactive,  and  had  dyspnoea  on  exertion. 

These  cases  of  extreme  fatty  growth,  or  of  extreme  degeneration,  of 
the  heart  are  much  rarer  than  those  of  which  I  have  now  to  speak. 

The  most  common  form  of  fatty  degeneration  is  that  in  which  you 
find,  on  opening  the  heart,  that  its  tissue  is  in  some  degree  paler  and 
softer  than  in  the  natural  state,  and  lacks  that  robust  firmness  which 
belongs  to  the  vigorous  heart.  But  what  is  most  characteristic  is,  that 
you  may  see,  especially  just  under  the  endocardium,  spots,  small 
blotches,  or  lines,  like  undulating  or  zigzag  transverse  bands,  of  pale, 
tawny,  bufi",  or  ochre-yellow  hue,  thick-set,  so  as  to  give,  at  a  distant 
view,  a  mottled  appearance.  These  manifestly  depend  not  on  any  de- 
posit among  the  fasciculi,  but  on  some  change  of  their  tissue.  For,  at 
their  borders,  you  find  these  spots  gradually  shaded-oif,  and  merging 
into  the  healthy  color  of  the  heart ;  and  when  you  examine  portions  of 
such  spots  with  the  microscope,  you  never  fail  to  find  the  fatty  degene- 
ration of  the  fibre. 

The  yellow  spotting,  or  transverse  marking  of  the  heart,  may  exist  in 
the  walls  of  all  its  cavities  at  once,  or  may  be  found  in  a  much  greater 
degree  in  one  than  in  the  others.  It  may  exist  in  all  parts  of  the 
thickness  of  the  walls,  or  may  be  chiefly  evident  beneath  the  endo- 
cardium and  pericardium.  It  is  far  less  common  in  the  auricles  than 
in  the  ventricles ;  and  when  it  exists  simultaneously  in  all  parts  it  is 
less  advanced  in  the  auricles.  It  is  more  common  in  the  left  ventricle 
than  in  the  right ;  and  in  the  left  ventricle  it  is  commonly  most  ad- 
vanced on  the  smooth  upper  part  of  the  septum,  and  in  the  two  large 
prominent  fleshy  columns.  Indeed,  it  may  exist  in  these  columns 
alone  ;  and  when,  in  such  a  case,  the  rest  of  the  heart  remains  strong, 
may  account  for  the  occasional  occurrence  of  rupture  of  the  columns. 

These  yellow  spottings  of  the  heart,  produced  by  degeneration  of 
scattered  portions  of  its  fibres,  are,  as  I  have  said,  the  most  evident, 
as  well  as  the  most  frequent,  indications  of  its  degenerative  atrophy. 
But  a  similar  afl'ection  may  exist  in  a  worse  form,  though  it  be  less 
manifest :  worse,  because  the  degeneration  is  more  extensive  and  more 
uniform ;  and  less  manifest,  because  it  is  less  distinctly  visible  to  the 
naked  eye,  and  must  be  recognized  by  the  touch  rather  than  by  the 
unaided  sight.  The  whole  heart  feels  soft,  doughy,  inelastic,  unresist- 
ing ;  it  may  be  moulded  and  doubled-up  like  a  heart  beginning  to  de- 
compose long  after  death :  it  seems  never  to  have  been  in  the  state  of 
rigor  mortis.  These  conditions  are  more  manifest  when  a  section  is 
made  through  the  wall  of  the  left  ventricle.  Then,  if  the  wall  be  only 
partly  cut  through,  the  rest  of  it  may  be  very  easily  torn,  as  if  with 
separation  of  fibres  that  only  stick  together  ;  and  the  cut  surface  of  the 
wall  looks,  as  it  were,  lobulated  and  granular,  almost  like  a  piece  of 
soft  conglomerate  gland,  an  appearance  which  is  yet  more  striking  when 
observed  with  a  simple  lens  of  about  half  an  inch  focus.     In  color,  the 


THE     HEART. 


10.' 


heart  has  not  on  its  surface,  much  less  on  its  section,  the  full  ruddy 
brown  of  healthy  heart,  a  color  approaching  that  of  the  strong  volun- 
tary muscle;  but  is,  for  the  most  part,  of  a  duller,  dirtier,  lighter 
brown,  in  some  parts  gradually  blending  with  irregular  marks  or 
blotches  of  a  paler  fawn,  or  dead-leaf  color. 

These  appearances  of  the  degenerate  heart  may  be  variously  mingled ; 
and  they  may  be  variously  associated  with  overgrowths  of  the  external 
fat,  or  Avith  previous  hypertrophy  or  other  changes  of  structure  in  the 
heart.  But,  however  much  the  appearances  of  the  affection  may  be 
obscured,  the  general  characters  of  softness,  paleness,  mottled  color, 
and  friability,  will  be  suiEcient,  if  not  always  to  prove,  yet  always  to 
excite  suspicion,  that  the  fatty  degeneration  of  the  heart  exists :  and, 
if  only  suspicion  is  excited,  the  microscopic  examination  may  be  always 
decisive.  The  chief  microscopic  appearances  are  delineated  in  the 
subjoined  sketch. 

When  a  portion  of  the  heart's  walls,  especially  if  they  are  very  soft, 
is  dissected  in  the  ordinary  way,  with  needles,  for  the  microscope,  the 
fibres  are  broken  into  short  pieces,  some  twice,  some  five  or  six  times, 
as  long  as  they  are  broad.  The  broken  ends  of  these  short  pieces  are 
usually  squared ;  but  some  are  round,  or  irregular,  or  cloven,  and 
broken  off  lower  down.  The  pieces  are  almost  always  completely 
separated,  having  no  appearance  of  even  cohering  at  their  sides,  and 
they  lie  scattered  disorderly. 

In  whichever  form  the  degeneration  is  examined,  you  may  find  that, 
in  some  pieces,  the  transverse  stride  are  still  well  seen  and  undisturbed, 

Fig.  6* 


62 


appearing  quite  as  in  health.  In  more,  they  are  interrupted  or  ob- 
scured by  dark  dots,  or  by  glistening  particles  with  shady  black  mar- 
gins,  like  minute  oil-particles    scattered  without   order  in  the  fibres. 

*  A.  Muscular  fibres  of  the  healthy  human  heart. 

B.   Fatty  degeneration  of  the  fibres  of  the   human  heart ;   b,  early  stage  ;  b^,  more  ad- 
vanced. 

O.  The  same,  yet  more  advanced,  all  magnified  400  times.     From  Dr.  Quain's  plates  : 
Med.  Chir.  Trans,  vol.  xxxiii,  pi.  3. 


106  ATROPHY    OF 

Where  such  particles  are  few,  they  appear  to  lie  especially,  or  only,  in 
contact  with  the  interior  of  the  sarcolemma ;  but,  where  more  numer- 
ous, they  appear  to  occupy  every  part  of  the  fibre,  leaving  the  trans- 
verse stride  discernible  only  at  its  margins,  or  even  completely  obscuring 
or  replacing  them,  and  making  the  fibre  look  like  a  gland-tube  filled  with 
dark  granules  and  larger  glistening  dark-edged  fat-particles.  Where 
these  particles  are  very  numerous  in  a  fibre,  they  appear  also  generally 
larger,  and  more  generally  glistening  and  black-edged,  like  larger  oil- 
particles. 

There  may  be  no  oil-drops  floating  about ;  no  fat-cells ;  scarcely 
even  any  of  the  minute  particles,  which  are  seen  in  the  fibres,  may 
appear  out  of  them  ;  the  field  of  the  microscope  may  be  perfectly  clean. 
In  these  minor  respects,  howeyer,  many  difi'erences  exist ;  though  I 
think  it  may  be  stated  that  the  degeneration  is  very  rarely,  if  ever, 
accompanied  by  any  morbid  product  deposited  between  the  fibres ; 
whatever  fatty  matter  may  appear  between  them,  is  only  such  as  has 
escaped  from  them. 

As  a  general  rule,  the  palest  parts  of  the  heart  are  most  advanced  in 
the  disease  ;  but  even  in  microscopic  portions  some  pieces  of  fibres 
appear  hardly  changed,  while  those  all  round  them  are  completely 
granular. 

I  alluded,  in  the  last  lecture,  to  the  defective  condition  of  the  nuclei 
of  degenerate  elemental  structures.  This  is  peculiarly  well  shown  in  the 
degenerate  fibres  of  the  heart.  When  those  of  a  healthy  heart  are 
placed  in  diluted  acetic  acid,  they  display  a  longitudinal  series  of  nuclei, 
at  nearly  equal  distances  apart,  and  usually  lying  in  the  middle  of  the 
presenting  surface  of  the  fibre.  Nuclei  of  this  form  are,  so  far  as  I 
know,  peculiar  to  the  heart-fibres.  They  are  large,  reddish-yellow,  like 
blood-globules,  especially  when  the  heart  is  very  robust :  they  are 
elongated,  oval,  or  nearly  quadrilateral ;  and  at  each  of  their  ends  one 
almost  always  sees  tapering  groups  of  small,  isolated,  yellowish  gra- 
nules, like  particles  separated  from  them,  and  gradually  withering.  But 
in  the  degenerate  fibre,  when  the  change  is  least  advanced,  the  outlines 
of  the  nucleus  look  dim,  and  it  loses  its  color :  when  the  change  has 
made  further  progress,  the  nucleus  cannot  be  seen  at  all,  though  its 
former  place  may  be  indicated  by  some  of  the  narrow  group  of  gra- 
nules ;  and  in  a  yet  later  stage,  when  the  sarcolemma  appears  nearly 
full  of  fatty  particles,  all  trace  is  lost  alike  of  the  nucleus  and  of  the 
granules. 

I  have  spoken  of  fatty  degeneration  of  the  heart  at  this  great  length, 
both  because  there  is  no  better  example  for  illustration  of  the  general 
pathology  of  such  afiections,  and  because  it  is  extremely  important  that 
this  condition  of  the  heart  should  be  recognized  after  death,  even  when 
no  suspicion  could  be  entertained  of  it  during  life.  For  it  often  intro- 
duces unexpected  dangers  into  the  ordinary  practice  of  surgery:  it  is, 
I  believe,  not  rarely  the  cause  of  sudden  death  after  operations  ;  it  is 


[-  THE    HEART.  107 

one  of  the  conditions  in  which  chloroform  should  be  administered  with 
more  than  ordinary  caution.  They  who  labor  under  it  may  be  fit  for 
all  the  ordinary  events  of  calm  and  quiet  life,  but  they  are  unable  to 
resist  the  storm  of  a  sickness,  an  accident,  or  an  operation.  And  let  it 
not  be  said  that  one  learns  little  in  learning  too  late  the  existence  of  an 
incurable  disease  ;  for  very  often  the  death  that  has  come  from  such  a 
disease  has  been  ascribed  to  a  wrong  cause,  and  has  spoiled  confidence 
in  good  men  and  their  good  measures.  Nor  does  the  caution  seem  un- 
necessary that,  serious  as  the  effects  of  the  disease  are,  the  change  of 
structure  may  escape  any  but  a  very  careful  and  practised  examiner. 
For,  often,  the  change  is  hardly  manifest  to  the  eye,  though,  while  it 
afiects  the  whole  heart,  it  may  have  destroyed  life.* 

Atrophy  of  the  organic  or  smooth-fibred  muscles,  doubtless  occurs, 
as  a  simple  decrease  of  them,  in  the  thinning  of  the  coats  of  the  intes- 
tines, stomach,  and  other  hollow  organs,  which  is  sometimes  associated 
with  general  emaciation,  or  with  diminished  function  :  but  the  change 
has  not  been  carefully  studied.  Of  the  fatty  degeneration  of  this  mus- 
cular tissue,  examples  are  described  in  the  muscular  coats  of  the  arte- 
ries, f  which  partake  in  the  corresponding  change,  or  atheromatous 
affection,  of  their  thickened  internal  coats;  in  the  coats  of  the  urinary 
bladder;!  and  in  the  uterus. §  In  the  latter  organ  the  change  has  pe- 
culiar interest ;  taking  place,  as  it  does,  quickly  after  the  fulfilment  of 
office  in  parturition  :  affecting  all  the  muscular  fibro-cells  which,  during 
gestation,  Ixad  been  developed  to  their  perfection  ;  and  preceding  their 
absorption  and  replacement  by  new-formed  fibro-cells,  like  those  which 
existed  in  the  young  and  unimpregnated  uterus.  The  series  of  changes 
thus  traced  by  Kilian  tell  a  complete  history  of  nutrition,  in  the  suc- 
cession of  development  and  growth  to  perfection,  of  discharge  of  func- 
tion, consequent  degeneration,  absorption,  and  replacement  by  new 
structures  that,  in  their  progress,  pass  through  the  same  phases  as 
their  predecessors.  The  production  of  fat  in  the  uterine  tissue  confirms 
also  the  probability  which  I  have  already  mentioned  (p.  60),  that  fat  is 
one  of  the  usual  results  of  the  chemical  change  which  takes  place  in 
muscular  action,  and  is,  in  this  relation,  a  substance,  like  the  kreatine, 


*  When  the  lecture  was  delivei'ed  in  1847,  I  related  some  cases  of  sudden  death  from 
this  affection ;  and  expressed  the  hope  that  its  whole  clinical  history  would  be  traced  by  Dr. 
Ormerod,  who  helped  me  very  much  in  investigating  its  morbid  anatomy.  The  hope  has 
been  fulfilled  far  beyond  my  expectation  by  both  him  and  Dr.  R.  Quain,  who  was,  at  the 
same  time,  actively  occupied  with  a  similar  course  of  inquiry.  I  may  therefore  refer  the 
reader  to  their  essays,  in  the  Medical  Gazette  for  1849,  vol.  ii ;  and  in  the  Medico-Chirurgi- 
cal  Transactions,  vol.  xxxiii ;  essays,  valuable  alike  for  the  importance  of  their  facts,  and  for 
the  thoroughly  scientific  spirit  in  which  they  are  conceived. 

f  Rokitansky,  Pathol.  Anat.,  ii,  p.  543 ;  KoUiker,  Zeitschr.  fiir  wissench.  Zoologie,  i, 
p.  81. 

X   Mr.  Hancock,  as  quoted  by  Mr.  Barlow,  Med.  Times  and  Gazette^  May  15,  1852. 

I  Koiliker,  1.  c.  p.  73.  Kilian,  in  Henle  and  Pfeufer's  Zeitschr.  fiir  rat.  Medicin,  vols, 
viii  and  ix. 


108  ATROPHY  or 

which  is  also  found  in  the  uterine  tissue  after  birth,*  intermediate  and 
transitional  between  the  proper  constituents  of  the  tissues  and  the  oxi- 
dized materials  of  excretions.  It  may  be  added,  that  the  whole  sub- 
stance of  the  uterus  and  its  membranes  partakes  of  the  degenerative 
change,  and  that  the  removal  of  the  old  tissues  and  the  formation  of 
new  ones  is  so  total,  that,  as  it  has  been  justly  said,  a  person  has  a  new 
uterus  after  each  delivery.  But  the  peculiarity  of  the  case  is  only  in 
that  the  change  is  accomplished  quickly,  manifestly,  and  simultaneously 
in  a  large  mass  of  tissue  :  in  the  same  sense,  though  at  unknown  times, 
men  have  often  new  hearts,  new  glands,  and  new  brains. 

In  the  bones  we  may  probably  consider  that  a  calcareous  degenera- 
tion occurs  as  a  method  of  atrophy,  in  addition  to  those  just  described 
in  the  muscles  :  for  to  such  a  degeneration  we  may  ascribe  the  increased 
proportion  of  bone-earths  in  the  skeletons  of  aged  persons.  The  aug- 
mentation of  earthy  constituents  is  not  attended  with  increased  strength 
of  the  bones  :  rather,  they  become,  in  old  persons,  thin-walled,  and 
more  easily  broken ;  the  change  being  commonly  associated  with  both 
wasting  and  fatty  degeneration,  and  the  whole  tissue  being  rarefied.  It 
is  through  this  general  want  of  compactness  in  their  construction  that 
old  bones  are  weak :  for,  as  Dr.  Stark's  analyses  show  very  well,  the 
strength  of  bones  depends  more  on  their  compactness  than  on  the  pro- 
portion of  their  constituents. 

I  am  not  aware  that  any  analyses  of  diseased  or  other  bones  have 
shoAvn  a  calcareous  degeneration  of  them,  except  in  old  age  :  but  its 
frequent  occurrence  is  highly  probable.  The  other  modes  of  atrophy 
may  be  more  fully  illustrated  in  the  two  forms  already  often  referred 
to.  The  simple  wasting  of  a  bone  is  a  common  change.  Examples 
have  been  already  adduced  in  connection  with  the  subject  of  unequal 
length  of  the  limbs  (p.  78),  and  with  that  of  the  effects  of  pressure  (p. 
80),  as  well  as  in  relation  to  the  general  history  of  atrophies.  Among 
many  specimens  in  the  College  Museum,  the  most  striking  is  the  skele- 
ton of  a  hydrocephalic  patient  from  the  collection  of  Mr.  Listen  (No. 
3489).  It  is  the  more  remarkable,  because,  AA'hile  all  the  bones  of  the 
trunk  and  limbs  are  reduced,  by  atrophy,  to  exceeding  thinness  and 
lightness,  the  bones  of  the  cranium  are  as  exceedingly  enlarged  in 
adaptation  to  the  enormous  volume  of  their  contents. 

Another  interesting  specimen  is  a  skull  (No.  8)  fitted  up  by  Hunter 
to  show  the  movements  of  the  edentulous  lower  jaw,  as  he  has  described 
them  in  his  "  Natural  History  of  the  Teeth."  It  shows  the  atrophy 
not  only  of  the  alveolar  margins,  but  of  every  part  of  the  jaws,  and 
even  of  their  palatine  parts,  and  those  of  the  palate  bones,  which  are 
quite  thin  and  transparent, f 

*  Siegmund,  in  the  Wiirzburg  Verhandlungen,  B.  iii,  H.  1. 

J  But  in  the  skulls  of  old  persons  the  atrophy  is  not  necessarily  limited  to  the  jaws  and 
other  bones  of  the  face.     The  cranial  bones  frequently  participate,  they  become  thin,  and 


THE    BONES.  109 

A  rare  specimen  of  atrophy  of  the  lower  jaw  is  shown  in  a  case  of 
complete  osseous  anchylosis  of  both  temporo-maxillary  articulations, 
from  Mr.  Howship's  Museum  (No.  966).  Similar  atrophy  of  bone  in 
its  extreme  state  is  illustrated  by  an  example  of  anchylosis  of  the  knee 
(No.  384),  from  the  case  described  by  Mr.  Thurnam.*  Considerable 
apertures  are  formed  in  the  wasted  walls  of  the  femur  and  tibia,  and  they 
were  covered  in  by  the  periosteum  alone  :  the  whole  thickness  of  these 
portions  of  the  walls  having  been  removed  in  the  progress  of  the  atro- 
phy. In  the  Museum  of  St.  Bartholomew's  is  a  specimen  in  which 
simple  atrophy  of  the  femora  led  to  such  fracture  as,  being  effected  by 
a  slight  force,  is  called  spontaneous.  The  atrophy  of  these  bones  oc- 
curred coincidently  with  extreme  emaciation  of  all  the  other  parts,  as 
well  as  of  the  skeleton  ;  an  emaciation  which  was  to  be  ascribed,  I  be- 
lieve, more  to  starvation  than  to  anything  else.  The  shafts  of  the 
femora  are  exceedingly  small,  and  their  walls  are  so  thin  that,  although 
their  texture  appears  healthy,  they  could  not  resist  the  force  of  the 
muscles  acting  on  the  articular  ends.  They  broke:  and  the  result 
shows  a  remarkable  example  of  the  capacity  for  repair  of  injuries  even 
while  the  process  of  ordinary  nutrition  seems  almost  suspended :  for  the 
fractures  were  firmly  reunited. 

I  might  greatly  multiply  examples  of  such  simple  wasting  atrophy 
of  bones  ;  but  let  these  suffice,  that  I  may  speak  now  of  fatty  degenera- 
tion of  the  bones. 

I  have  already  said  that  it  is  common,  in  many  atrophied  bones,  to 
find  an  excess  of  fatty  matter  ;  I  referred  to  old  bones  laden  with  fat 
as  examples  of  a  form  of  senile  atrophy ;  and  sometimes,  in  cases  of 
diseased  joints,  the  form  of  atrophy  assumed  by  the  disused  bones  is 
that  not  merely  of  exceeding  thinness  of  the  walls  and  wasting  of  the 
cancelli,  but  of  an  accumulation  of  soft  fat,  filling  every  interstice  and 
maintaining  the  size  of  the  bone.  But  it  is  now  to  be  added,  that  the 
bones,  like  other  organs,  are  liable  to  a  fatty  degeneration,  which,  be- 
cause of  the  obscurity  of  its  origin,  we  must  be  content  to  call  spontane- 
ous ;  and  this  fatty  degeneration  of  the  bones  is  the  disease  which  most 
English  writers  have  described  as  Mollities  Ossium. 

The  Museum  of  the  College  has  a  remarkably  rich  collection  of  speci- 
mens of  this  disease  :  a  collection  embracing  specimens  from  nearly  all 
the  cases  with  whose  histories  we  are  most  familiar. 

undergo  a  marked  diniiniuion  in  weigVit.  These  changes  have  been  caiefully  examined 
by  Virchow  ^Wurzburg  Verhandlung,  B.  iv,  p  354;  Gesam.  Abhandl.  p.  1000),  and  de- 
scribed by  him  as  a  "  Malum  senile."  The  old  centres  of  ossification,  as  the  eminences  cf 
the  parietal  bones,  are  chiefly  afiected.  The  wasting  begins  from  without,  thinning  and 
gradually  removing  the  outer  table,  then  the  diploe,  and  at  last,  perhaps  the  inner  table 
itself  In  some  cases  the  diploe  may  hardly  undergo  any  change,  in  others  its  lamellae  fuse 
together,  and  form  a  compact  layer,  so  that  it  looks  like  an  outer  table.  Along  with  this 
thinning  from  without  a  formation  of  new  bone  may,  at  the  same  time,  take  place  within 
the  skull. 

*  Medical  Gazette,  vol.  xxiii,  p.  119. 


110  ATROPHY    OF 

Well-marked  examples  of  the  fatty  degeneration  are  shown  in  No. 
400.  These  are  two  femora  fractured  by  a  slight  force,  and,  in  their 
dried  state,  light,  very  greasy,  mahogany-brown,  and  so  soft  that  you 
may  crush  many  parts  of  them  with  the  fingers.  Their  excess  of  fat 
is  evident ;  but  no  more  of  their  history  is  known  than  that  they  came 
from  an  elderly,  if  not  an  old,  man, — an  Archbishop  of  Canterbury. 

In  No.  398  is  a  section  of  a  humerus,  affected  as  many  other  bones 
of  the  same  person  were,  with  extreme  fatty  degeneration  ;  and  the 
Catalogue  contains,  with  its  description,  a  reprint  of  an  essay,  by  Mr. 
Hunter,  which  escaped  even  the  careful  research  of  the  editor  of  his 
works,  Mr.  Palmer.  His  essay  is  entitled,  "  Observations  on  the  Case 
of  Mollities  Ossium  described,"  &c.,  by  Mr.  Goodwin,  in  the  "Lon- 
don Medical  Journal."*  It  was  communicated  in  a  letter  to  Dr. 
Simmons,  the  editor  of  that  journal ;  and  I  will  quote  one  passage,  to 
show  both  what  was  the  original  appearance  of  the  bones,  and  how 
completely  Mr.  Hunter's  description  confirms  the  opinion  that  this 
mollities  ossium  was  really  a  fatty  degeneration  of  the  bones.  He  says, 
speaking  of  this  humerus,  "  The  component  parts  of  the  bone  were  to- 
tally altered,  the  structure  being  very  different  from  other  bones,  and 
wholly  composed  of  a  new  substance,  resembling  a  species  of  fatty 
tumor,  and  giving  the  appearance  of  a  spongy  bone,  deprived  of  its 
earth,  and  soaked  in  soft  fat." 

Nothing  can  better  express  the  character  of  the  change,  or  its  simi- 
larity to  the  fatty  degenerations  of  other  organs,  in  which  we  find  the 
proper  substance  of  the  part  gradually  changed  for  fat,  and  the  whole 
tissue  spoiled,  while  the  size  and  outer  form  of  the  part  remain  unal- 
tered. 

The  same  characters  are  shown  in  the  often-quoted  case  by  Mr. 
Howship,  of  which  specimens  are  preserved  in  Nos.  401—2—3.  The 
last  of  these  specimens  shows  what  remained  of  the  upper  part  of  a 
femur  after  boiling ;  scarce  anything  besides  a  great  quantity  of  white 
crystalline  fatty  matter. 

It  is  the  same  with  a  femur  (No.  403  B)  presented  to  the  Museum 
by  Mr.  Tamplin,  in  the  examination  of  which  I  first  obtained,  with  the 
microscope,  the  conviction  of  the  nature  of  the  change  which  constitutes 
what  we  call  mollities  ossium.  This  has  the  same  characters  as  the 
specimens  already  shown,  and  the  medulla  of  the  bone  had  the  bright 
yellow,  pink,  and  deep  crimson  hues,  which  are  so  striking  in  many 
instances  of  the  disease.  But  the  constituents  of  this  apparently 
peculiar  material  were,  free  oil  in  great  quantity ;  crystals  of  marga- 
rine, free,  or  inclosed  in  fat-cells  ;  a  few  fat-cells  full  of  oil  as  in  health, 
but  many  more,  empty,  collapsed,  and  rolled  up  in  strange  and  decep- 
tive forms.  The  pink  and  crimson  colors  were  OAving  to  the  bright 
tints  of  a  part  of  the  oil-globules,  and  of  the  nuclei  and  granules  in  the 

*  Vol.  vi,  1785. 


THE    BONES.  Ill 

collapsed  fat-cells  ;  and  there  was  no  appearance  whatever  of  an  excess 
of  blood  in  the  bone,  or  any  of  its  contents.* 

From  this  examination,  therefore,  as  well  as  from  all  the  other  facts, 
1  concur  entirely  in  Mr.  Curling's  opinion  respecting  this  disease. f  A 
specimen  (No.  403  A)  from  the  case  on  which  he  chiefly  founded  his 
opinion,  and  which  he  has  very  accurately  described,  closely  resembles 
those  I  have  referred  to.  He  proposes  the  name  "  Eccentric  Atrophy 
of  Bone"  to  express  one  of  the  principal  characters  of  the  disease;  and 
I  would  have  adopted  it,  as  preferable  to  "  Osteoporosis,"  under  which 
I  think  Rokitansky  would  include  these  cases,  but  that  it  seems  desira- 
ble to  class  this  affection  with  others  to  which  it  bears  the  closest 
analogy,  by  giving  it  the  same  generic  name  in  the  designation,  fatty 
degeneration  of  bones. 

The  cases  above  referred  to  included  the  principal  examples  of  the 
disease  observed  and  recorded  in  England  under  the  name  of  mollities 
ossium  up  to  the  period  of  publication  of  the  first  edition  of  these  lec- 
tures ;  and  to  these,  I  think,  might  be  added  the  case  described  by 
Mr.  Solly,J  for  the  appearances  presented  by  the  femur  (No.  403  C) 
are  strikingly  similar  to  those  in  the  specimens  already  referred  to, 
and  the  material  filling  its  medullary  cavity  contained  abundant  fatty 
matter.  Since  that  time  two  additional  cases  have  been  recorded,  one 
by  Dr.  T.  K.  Chambers§  in  a  female,  set.  26,  in  whom,  so  far  as  the 
examination  was  conducted,  not  only  the  bones,  but  the  muscles,  had 
undergone  fatty  degeneration;  and  a  second  by  Dr.  Ormerod,l|  which 
occurred  in  an  adult  male,  subsequently  to  the  age  of  thirty,  and 
affected  the  skeleton  generally.^ 

You  might  ask,  then,  what  is  the  real  mollities  ossium?  or  is  there 
such  a  disease  different  from  what  these  specimens  show  ?     I  could  not 

*  It  should  bfe  stated,  however,  that  Litzmann  has  described  i'n  the  beginning  of  the 
disease,  the  medulla  as  being  very  rich  in  blood,  vi^hich  is  partly  contained  in  the  vessels. 
and  partly  extravasated.  He  states  that,  on  making  a  microscopic  examination,  numerous 
unchanged  blood-corpuscles,  and  abundant  groups  of  brown-red  pigment  granules,  may  be 
recognized.  See  his  Beitrage  zur  Kenntniss  der  Osteomalacic,  translated  by  Dr.  M.  Dan- 
can,  in  the  Ed.  Med.  Jal.,  1861-62.  In  this  essay,  Litzmann  includes  under  the  term 
osteomalacia,  the  cases  which  have  been  described  as  mollities  ossium,  osteoporosis,  eccentric 
atrophy,  malakosteon.  He  regards  the  disease,  whether  it  occurs  in  the  male  or  female,  in 
the  bones  of  the  extremities,  or  thos^of  the  trunk,  as  the  same. 

t  Med.  Chir.  Transactions,  vol.  xx. 

J  Med.  Chir.  Trans.,  vol.  xxvii.  ^   Ibid.,  vol.  xxxvii.,  ,1854. 

II   British  Medical  Journal,  Sept.  1859. 

^  One  may  occasionally  observe  in  the  dissecting-room  the  ribs  of  old  subjects  so  softened 
that  they  may  be  easily  bent  in  various  directions  without  breaking.  In  these  cases  it  may 
be  seen  that  the  earthy  matter  has  been  more  or  less  replaced  by  a  soft,  fatty  substance. 
Retzius  has  described  and  figured  (Museum  Anat.  Holmiense,  1855)  a  very  remarkable 
cranium,  the  bones  of  which,  especially  at  the  base,  were  so  infiltrated  with  a  fatty  deposit, 
that  considerable  distortion,  with  great  alterations  in  the  size  and  shape  of  the  various 
cranial  foramina,  had  taken  place.  Additional  cases  of  mollities  ossium  occurring  in  Britain 
have  been  recorded  in  the  Edinburgh  Medical  Journal,  August,  1862,  by  Dr.  W.  C.  Mcintosh, 
of  Perth,  and  in  the  Transactions  of  the  Medico-Chirurgical  Society  of  London,  vol.  xlv, 
1862,  by  Dr.  Robert  Barnes. 


112  ATROPHY    OF 

from  my  own  observations  answer  such  a  question ;  for  I  have  never 
seen  a  specimen  which  appeared  to  fulfil  in  any  degree  the  general 
notion  of  mollities  ossium,  as  a  disease  consisting  in  the  removal  of  the 
earthy  matter  of  bone,  and  the  reduction  of  any  part  of  the  skeleton  to 
its  cartilaginous  base.  I  do  not  doubt  the  accuracy  of  what  others 
have  written  of  such  an  affection ;  but  I  am  sure  that  the  cases  I  have 
cited  are  not  simple  softenings  of  bone,  but  fatty  degenerations ;  and 
that  those  cases  must  be  very  different  to  which  Rokitansky  refers 
under  the  names  of  Osteomalacia,  Malakosteon,  Knochenerweichung, 
and  Rachitismus  adultorum.  He  gives,  as  a  characteristic  of  the 
disease,  that  it  affects  the  bones  of  the  trunk,  or  a  part  of  them,  much 
more  often,  and  more  severely,  than  the  bones  of  the  extremities,  and 
occurs  especially  after  child-bed.  Now,  in  the  cases  which  I  have  en- 
deavored to  illustrate,  the  extremities,  not  the  trunk,  are  the  chief  seats 
of  the  disease ;  and  there  is  no  evidence  of  the  fatty  degeneration  oc- 
curring more  often  after  delivery  than  in  any  other  period  or  condition 
of  life.  So  that,  on  the  whole,  I  think  we  may  consider  there  are  two 
diseases  included  under  the  name  of  mollities  ossium ;  namely,  the  fatty 
degeneration  which  these  specimens  show,  and  which  seems  to  be  the 
more  frequent  in  England;  and  the  simpler  softening  of  bone,  or 
rickets  of  the  adult,  to  which  Rokitansky's  description  alludes,  and  in 
which  the  bones  are  flexible  rather  than  brittle,  and  appear  reduced  to 
their  cartilaginous  state.  This  affection  seems  to  be  more  frequent 
than  the  fatty  degeneration  in  Germany  and  France ;  and  I  think  the 
only  probable  well-recorded  instance  of  its  occurrence  in  England,  is 
that  related  by  Mr.  Dalrymple,*  Dr.  Bence  Jones, f  and  Dr.  Macintyre.J 
I  feel,  however,  that  there  is  still  much  doubt  respecting  the  relations 
of  these  affections ;  they  are,  perhaps,  more  nearly  allied  than,  at  first 
sight,  they  may  seem  ;  and  I  think  some  clue  to  their  alliance  may  be 
obtained  from  the  relation  which  they  both  have  to  the  rickets  of  the 
young  subject.  The  relation  is  best  shown  in  the  bones  of  the  skull, 
and  is  illustrated  by  specimens  in  the  College  Museum  (Nos.  392  to  396, 
and  2857  to  2860) ;  but  I  need  not  now  dwell  on  it  while  wishing  to 
give  only  a  general  account  of  the  atrophies  of  bones. § 

I  can  scarcely  doubt  that  future  inquiries  will  ascertain  that,  in  every 
tissue,  changes  such  as  these  which  I  have  described  in  muscle  and  in 
bone  are  the  results  of  simply  defective  nutrition.  But  I  have  neither 
knowledge  nor  space  for  more  than  a  few  additional  instances.  Among 
these,  the  degenerations  of  bloodvessels  may  be  cited.  The  blood- 
vessels of  an  atrophied  part,  I  have  already  said,  decrease  in  adapta- 

*  Dublin  Journal  of  Med.  Science,  vol.  ii,  1S46. 

t  Philos.  Trans.,  1848.  J  Medico  Chir.  Trans.,  vol.  xxxiii. 

§  I  have  minutely  described  the  specimens  here  referred  to,  as  well  as  the  later  changes 
which  the  bones  undergo,  in  the  Pathological  Catalogue  of  the  College  Museum,  vol.  ii,  p.  22, 
and  vol.  v,  p.  7. 


THE    BLOODVESSELS.  113 

tion  to  the  part :  they  become  less,  till  they  can  carry  no  more  blood 
than  is  just  enough  to  meet  the  diminished  requirements  of  nutrition  : 
and  this  they  do,  not  by  such  muscular  contraction  as  adapts  them  to 
a  temporary  decrease  of  function  in  a  part,  but  (if  one  may  so  speak) 
by  a  diminishing  growth.  Moreover,  when  a  part  degenerates,  its 
bloodvessels  are  likely  to  degenerate  in  the  same  manner.  There  are, 
I  think,  instances  in  which  fatty  degenerations  of  bloodvessels  have 
occurred  in  consequence  of  similar  change  in  the  part  that  they  supply. 
But  the  more  interesting  examples  are  those  of  primary  degeneration 
of  the  bloodvessels.  This  has  been  long  known  in  the  atheromatous 
disease,  as  it  was  called,  of  the  larger  arteries ;  the  true  nature  of 
which,  as  a  fatty  and  calcareous  degeneration  of  the  inner,  and,  con- 
secutively, of  the  middle  arterial  coat,[was  discovered  by  Mr.  Gulliver.* 
The  descriptions  of  this  affection  by  him,  and  by  Rokitansky,  and  Vir- 
chow,  have  left  nothing  unsaid  that  is  yet  known.  Observations  are 
each  year  becoming  more  numerous  and  interesting  of  fatty  degenera- 
tion occurring  even  in  the  smallest  bloodvessels.  Such  changes  are 
especially  observable  in  the  minutest  cerebral  vessels  ;  and  their  im- 
portance, in  relation  to  apoplexy,  of  which  they  seem  to  be  the  most 
frequent  precedent,  as  well  as  for  the  general  illustration  of  the  minute 
changes  on  which  the  defective  nutrition  of  organs  may  depend,  will 
justify,  I  hope,  my  repeating  the  description  which  I  wrote  from  the 
first  instances  in  which  they  were  observed,  and  has  since,  I  think,  been 
sufficiently  confirmed. f 

In  the  least  degrees  of  this  affection,  the  only  apparent  change  of 
structure  is,  that  minute,  shining,  black-edged  particles,  like  molecules 
of  oiljj  are  thinly  and  irregularly  scattered  beneath  the  outer  surface 
of  the  small  bloodvessels  of  the  brain.  Such  a  change  may  be  seen 
in  the  vessels  of  portions  of  the  brain  that  appear  quite  healthy,  as  well 
in  the  capillaries  as  in  branches  of  both  arteries  and  veins  of  all  sizes, 
from  l-150th  of  an  inch  in  diameter  to  those  of  smallest  dimension. 

As  the  disease  makes  progress,  the  oil-particles  may  increase  in  num- 
ber till  the  whole  extent  of  the  affected  vessels  is  thick-set  with  them, 
and  the  natural  structures,  even  if  not  quite  wasted,  can  hardly  be  dis- 
cerned. While  their  number  thus  increases,  there  is,  also,  usually,  a 
considerable  increase  of  the  size  of  many  of  the  oil-particles,  and  they 
may  be  seen  of  every  size,  from  an  immeasurable  minuteness  to  the 
diameter  of  l-2000th  of  an  inch.      In  other  places  one  sees,  instead  of 

*  Medico-Chirurg.  Trans,  vol.  xxvi,  p.  86.  t  Medical  Gazette,  vol.  xlv. 

J  Dr.  Jenner  (Med.  Times  and  Gaz.,  Jan.  31,  1852)  has  shown  that  these  appearances  of 
oil-particles  are  very  closely  imitated  by  equally  minute  particles  similarly  depo.sited, 
but  which  are  proved  to  be  calcareous  by  their  solubility  in  hydrochloric  acid.  I  think  it  very 
probable  that  what  I  have  here  described  as  fatty  or  oily  matter  may  often  be,  at  least  in 
part,  calcareous;  we  may  reasonably  expect  this  affection  of  the  small  vessels  to  be  exactly 
analogous  to  the  common  fatty  and  calcareous  degeneration  of  the  larger  arteries,  although 
there  is  no  generality  of  coincidence  between  them.  I  have  also  seen  a  pigmental  degene- 
ration of  small  cerebral  arteries  very  similar  to  the  fatty  one  described  above. 


114  ATROPHY    OF 

this  increase  of  scattered  oil-particles,  or  together  with  it,  groups  or 
clusters  of  similar  minute  particles,  which  are  conglomerated,  some- 
times in  regular  oval  or  round  masses,  like  large  granule- cells,  but  more 
often  in  irregular  masses  or  patches,  in  the  wall  of  a  great  part  of  the 
circumference  of  a  bloodvessel. 

In  a  single  fortunately  selected  specimen,  one  may  see,  in  different 
branches  of  a  vessel,  all  these  degrees  or  states  of  the  degeneration, — 
the  less  and  the  more  thickly  scattered  minute  oil-particles,  the  clusters 
of  such  particles  in  various  sizes  and  shapes,  and  the  larger  particles  like 
drops  of  oil. 

When  the  degeneration  has  made  much  progress,  changes  in  the 
structure,  and,  not  rarely,  changes  in  the  shape  also,  of  the  affected 
bloodvessels  may  be  observed.  The  chief  change  of  structure  appears 
to  consist  in  a  gradual  wasting  'of  the  more  developed  proper  structures 
of  the  vessels  :  growing  fainter  in,  apparently,  the  same  proportion  as 
the  disease  makes  progress,  the  various  nuclei  or  fibres  are  at  length 
altogether  lost,  and  bloodvessels  of  even  l-150th  of  an  inch  in  diameter 
appear  like  tubes  of  homogeneous  pellucid  membrane,  thick-set  with  the 
fatty  particles.  The  structures  of  the  vessels  are  not  merely  obscured 
by  the  abnormal  deposits ;  they  waste  and  totally  disappear. 

The  changes  of  shape  which  the  vessels  may  at  the  same  time  un- 
dergo are  various.  Very  commonly,  the  outer  layer  of  the  wall  is 
lifted  up  by  one  or  more  clusters  of  oil-particles,  and  the  outline  of  the 
vessels  appears  uneven,  as  if  it  were  tuberous  or  knotted.  Sometimes 
the  outer  or  fibro-cellular  coat  of  the  vessels  is  for  some  distance  raised 
far  from  the  middle  coat,  as  if  it  were  inflated,  and  the  space  between 
them  contains  numerous  particles  of  oil.  (But,  perhaps,  this  raising 
up  of  the  outer  coat  is  often  produced  by  water  being  imbibed  while 
preparing  the  specimen  for  examination.)  Sometimes,  but  I  think 
only  in  vessels  of  less  than  l-500th  of  an  inch  in  diameter,  partial 
enlargements,  like  aneurismal  dilatations,  or  pouches,  of  their  walls  are 
found. 

The  vessels  most  liable  to  this  disease  are,  I  think,  the  arteries  of 
about  l-300th  of  an  inch  in  diameter  ;  but  it  exists,  generally,  at  the 
same  time,  in  the  veins  of  the  same  or  less  size.  As  a  general  rule 
(judging  from  the  specimens  hitherto  examined),  the  disease  decreases 
in  nearly  the  same  proportion  as  the  size  of  the  vessels,  and  the  small- 
est capillaries  are  least,  if  at  all,  affected.  But  there  are  many  excep- 
tions to  this  rule ;  and  it  is  not  rare  to  find  vessels  of  from  l-2000th 
to  l-3000th  of  an  inch  in  diameter,  having  parts  of  their  walls  nearly 
covered  with  the  abnormal  deposits. 

The  principal  and  first  seat  of  the  deposits  is,  in  arteries,  in  the  more 
or  less  developed  muscular  or  transversely  fibrous  coat  :*  in  veins,  it  is 

"*  Virchow  (Cellular  Path.  p.  305)  states  that  the  fatty  degeneration  in  these  cases  is 
seated  in  the  outermost  layer  of  the  internal  coat.  He  considers  that  the  fatty  particles 
occupy  the  position   of  the  connective  tissue  corpuscles,  which  become  obscured,  or  even 


THE    BLOODVESSELS. 


115 


in  the  corresponding  layer,  immediately  within  their  external  fibrous 
nucleated  coat :  in  vessels,  whether  arteries  or  veins,  whose  walls  con- 
sist of  only  a  simple  pellucid  membrane  bearing  nuclei,  the  substance 
of  this  membrane  is  the  first  seat  of  the  deposits.  In  some  cases,  the 
outer  fibrous  coat  of  both  arteries  and  veins  appears  to  contain  abun- 
dant fatty  matter.     But  it  is  seldom  that,  in  an  advanced  stage  of  the 


Fig.  7* 


Fig.  8. 


l!!0'^^ff^M^&m^^ 


afiection,  any  of  the  several  coats  of  a  bloodvessel  can  be  assigned  as 
its  chief  seat ;  for  even  in  large  four-coated  arteries  they  wholly  waste, 
and  their  remains  appear  united  in  a  single  pellucid  layer,  of  which  the 
whole  thickness  may  be  occupied  by  the  deposit. 

The  figures  represent  some  of  the  most  usual  appearances  of  the  de- 
generation. 

The  cases  in  which  these  changes  were  first  observed  were  cerebral 
apoplexies  in  which  the  hemorrhage  appeared  certainly  due  to  rup- 
ture of  the  wasted  and  degenerate  bloodvessels.  The  probability  of 
such  an  event  is  evident ;  as  it  is,  also,  that  the  less  sudden  eff"ect  of 


completely  hidden,  by  the  fatty  degeneration  of  their  substance.  Owing  to  these  corpuscles 
being  branched  cells,  a  stellate  arrangement  of  the  fatty  masses  may  be  often  seen. 

*  Fig.  7.  An  artery,  of  l-300th  of  an  inch  in  diameter,  and  a  branch  given  from  it, 
from  a  softened  corpus  striatum.  Numerous  oil-particles  of  various  sizes  are  scattered  in 
the  muscular  coat,  traces  of  the  tissue  of  which  appear  in  obscure  transverse  marks. 

Fig.  8.  From  the  same  part,  a  vein  l-600th  of  an  inch  in  diameter,  with  branches  from 
l-1200th  to  1-1 800th,  and  portions  of  capillaries.  Scattered  oil-particles,  and  groups  like 
broken  irregular  granule-cells,  are  seen  in  the  homogeneous  pellucid  walls  of  all  the  vessels. 

Fig.  9.  A  vessel  of  l-600th  of  an  inch  in  diameter,  and  another  of  1-1 800th,  with  a  branch 
of  l-3000th  of  an  inch.  Groups  and  scattered  oil-particles  are  thick-set  in  the  simple,  pel- 
lucid, membranous  walls. 


116  ATROPHY    OF 

this  condition  of  the  vessels  is  likely  to  be  a  gradual  degeneration  of 
the  parts  of  the  brain  which  they  supply.  The  relation  between  organs 
and  their  bloodvessels  must  in  this  respect  be  mutual  :  in  the  same 
measure,  though  not  in  the  same  way,  as  atrophy  of  an  organ,  whether 
wasting  or  degenerative,  induces  a  corresponding  atrophy  of  its  blood- 
vessels, so  will  the  imperfection  of  degenerate  vessels  lead  to  atrophy 
of  the  part  in  which  they  are  distributed. 

I  suppose  that  the  minute  bloodvessels  of  many  other  parts  might 
be  often  found  thus  degenerate,  if  we  could  examine  them  as  easily  as 
we  can  those  of  the  brain  ;  but  I  am  not  aware  that  any  have  been  so 
described  except  those  of  the  eye,  in  the  cases  of  arcus  senilis,  to  which 
I  shall  presently  refer,  and  those  of  the  lungs  and  placenta.  In  the 
lungs,  Dittrich*  has  traced  affections  of  the  arteries  which,  he  says,  the 
account  I  have  given  above  exactly  fits,  and  the  consequences  of  which, 
in  pulmonary  apoplexy,  correspond  with  the  cerebral  apoplexies  due  to 
rupture  of  the  small  bloodvessels  of  the  brain. 

Many  facts  of  exceeding  interest  are  known  concerning'  the  degene- 
rations of  nervous  tissues,  but,  as  yet,  they  are  rather  fragments  than  a 
continuous  history. 

First,  in  relation  to  the  causes  of  degeneration,  two  are  chiefly  known ; 
namely,  defect  of  blood,  and  arrested  function.  Cases  of  softening  of 
the  brain  have  been  long  recognized  as  the  consequences  of  ligature,  or 
obstructive  disease,  of  the  carotid  or  other  large  arteries ;  but  they  have 
received  a  new  interest  from  the  discovery  by  Virchow,  and  indepen- 
dently by  Dr.  Kirkes,  of  their  frequency  in  consequence  of  the  obstruc- 
tion of  healthy  cerebral  arteries  by  masses  of  fibrine  carried  into  them, 
after  being  dislodged  from  the  valves  of  the  left  side  of  the  heart  or 
from  some  part  of  the  arterial  system.  In  these  cases,  the  extent  of 
softening  nearly  corresponds  with  the  range  in  which  the  branches  of 
the  obstructed  artery  are  distributed :  for,  beyond  the  circle  of  Willis, 
the  anastomosis  among  the  cerebral  arteries,  like  that  among  the  cardiac, 
is  not  sufficient  to  carry  a  full  supply  of  blood  into  a  part  from  which  the 
main  stream  is  hindered,  though  generally  enough  to  prevent  the  com- 
plete death  or  sloughing  of  the  part. 

Of  the  atrophy  following  diminished  or  abrogated  function  of  nervous 
parts  I  have  already  mentioned  examples  in  the  shrinking  of  the  brain 
in  old  people,  in  the  wasting  of  the  nerves  of  paralyzed  or  fixed  muscles, 
and  in  that  of  the  optic  nerve  and  tract  in  cases  of  blindness.  To  these 
may  be  added  the  cases  observed  by  Dr.  Waller  ;f  who  has  discovered 
that  when  a  nerve  is  divided,  its  distal  part,  i.  e.,  the  portion  between 
the  place  of  division  and  the  place  of  distribution,  the  portion  in  which 
the  nerve-office    can   be  no  longer  exercised,  always  suffers  atrophy, 

*  Ueber  den  Laennecschen  Lungen-infarktus.     Erlangen,  1850. 

f  Philos.  Trans.,  1S50,  Part  2  ;  and  in  the  London  Journal  of  Medicine,  July,  1852. 


THE    NERVOUS    TISSUES.  117 

wasting  and  degenerating.  The  same  atrophy  ensues  in  the  whole 
length  of  any  spinal  nerve  whose  root  is  divided ;  and  in  any  system  of 
nerves  through  which,  after  injury  of  the  spinal  cord,  reflex  actions  can- 
not be  excited.  The  change,  in  divided  nerves,  begins  at  the  distal 
extremities  of  the  nerve-fibres,  and  gradually  extends  upwards  in  the 
branches  and  trunk  of  the  nerve;  but  is  repaired  if  the  divided  portions 
of  the  nerve  be  allowed  to  reunite.  I  need  not  say  how  great  interest 
these  facts  have  in  relation  to  the  anatomy  and  physiology  of  the  ner- 
vous system:  but  it  is  equalled  by  those  related  by  Dr.  Turck,*  which 
may  be  used  for  ascertaining  the  functions  of  the  several  columns  of  the 
spinal  cord,  and  their  relations  to  the  different  parts  of  the  brain,  in  the 
same  manner  as,  by  those  of  Dr.  Waller,  knowledge  may  be  gained  of 
the  course  and  distribution,  and  of  the  centripetal  or  centrifugal  ofiice, 
of  the  several  nerves.  The  main  fact  discovered  by  Dr.  Turck  is,  that 
after  diseases  of  parts  of  the  brain  or  spinal  cord  there  gradually  ensues 
a  softening,  as  by  atrophy,  of  those  tracts  or  columns  of  the  cerebro- 
spinal axis,  through  which,  in  health,  impressions  were  habitually  con- 
veyed from  the  diseased  part.  The  same  general  truth  is  illustrated  by 
both  these  series  of  observations.;  namely,  that  nerve-fibres,  through 
which,  from  whatever  cause,  nerve-force  can  be  no  longer  exercised,  are 
gradually  atrophied.  The  atrophy  took  place  very  quickly  in  the  frogs 
that  were  the  subjects  of  Dr.  Waller's  experiments  :  commencing  in 
young  frogs,  during  the  summer,  in  from  three  to  five  days,  and  being 
completed  in  from  twenty  to  thirty  days.  But,  in  the  human  subject, 
the  process,  reckoned  by  the  observations  of  Turck,  and  those  in  which 
I  have  examined  nerves  atrophied  in  paralyzed  muscles,  is  much  slower. 
Changes  in  the  spinal  cord  are  not,  he  says,  discernible  in  less  than  half 
a  year  after  the  apoplexy  or  other  affection  of  the  brain  of  which  they 
are  the  consequence. 

The  changes  in  the  nerve-fibres  thus  atrophied  are  minutely  described 
by  Dr.  Waller.  At  first,  transverse  lines  appear  in  the  intratubular 
substance,  indicating  its  loss  of  continuity ;  then  it  appears  as  if  divided 
into  round  or  oblong  coagulated  masses,  as  if  its  two  component  ma- 
terials were  mingled ;  then  these  are  converted  into  black  granules, 
resisting  the  action  of  ether,  acids,  and  alkalies ;  and,  finally,  these 
granules  are  slowly  and  imperfectly  eliminated. f 

In  the  atrophies  of  the  brain  and  spinal  cord,  whether  from  ob- 
structed circulation  or  from  hindered  function,  the  chief  changes  that 
are  observed  are,  the  liquefaction  or  softening  of  the  whole  substance, 

*  Ueber  secundare  Erkrankung  einzelner  Riickenmarkstrange.     Wien,  1851. 

f  G.  Walter  has  recently  (Virchow's  Archivs,  1861,  vol.  xx,  p.  426)  re-examined  the 
changes  which  take  place  in  nerve-fibres  after  division.  He  distinguishes  the  following 
stages:  1st.  Coagulation  of  the  medullary  substance  in  the  nerve-fibre.  2d.  Resorption  of 
the  pre-existing  contents  of  the  medullary  sheath.  3d.  Fatty  degeneration  of  the  nuclei  of 
the  nerve  sheath.  4th.  Resorption  of  the  axial  cylinder,  after  cracking  and  breaking  up 
into  granules. 


118  ARCUS    SENILIS. 

the  breaking  up  of  the  nerve-fibres,  and  the  production  of  abundant 
granule-cells,  or  masses,  and  free-floating  granules.  Until  very  re- 
cently there  was  a  difficulty  in  accounting  for  the  origin  of  these 
granule-cells,  on  the  supposition  that  they  were  cells  undergoing  fatty 
degeneration,  as  it  was  thought  that  no  cell-structures  existed  in  the 
white  part  of  the  brain  and  spinal  cord.  But  the  discovery  by  Virchow 
in  the  great  nervous  centres  of  the  delicate  intei'mediate  form  of  con 
nective  substance,  termed  by  him  Neuroglia,  in  which  numerous  small, 
delicate,  corpuscles  are  imbedded,  and  the  observations  by  Lockhart 
Clarke  and  others  on  the  existence  of  a  fine  network  of  connective 
tissue  (in  which  multitudes  of  fine  cells  and  nuclei  are  interspersed) 
between  the  fibres  of  the  columns  of  the  cord,  supply  us  with  a  source 
from  which  these  fat-containing  granule-cells  may  be  derived.  * 

The  last  example  of  atrophy  of  which  I  will  speak  is  that  which  is 
manifested  in  the  Arcus  senilis, — the  dim  grayish-white  arches  or  ellipse 
seen  near  the  borders  of  the  cornea  in  so  many  old  persons.  Its  na- 
ture, as  a  true  fatty  degeneration,  consisting  in  the  accumulation  of  • 
minute  oil-drops  in  the  proper  tissue  of  the  cornea,  was  discovered  and 
is  fully  described  by  Mr.  Canton. f  By  his  and  others'|  investigations, 
it  has  also  acquired  a  larger  interest,  in  being  found  the  frequent  con- 
comitant and  sign  of  more  widely  extended  degenerations  that  are  not 
within  sight  during  life.  Thus,  it  is  commonly  associated  with  fatty  or 
calcareous  degeneration  of  the  ophthalmic  artery  ;  with  fatty  degenera- 
tion of  the  muscles  of  the  eyeball ;  and,  especially  in  old  persons,  with 
fatty  degeneration  of  the  heart  and  many  other  organs.  In  short,  the 
arcus  senilis  seems  to  be,  on  the  whole,  the  best  indication  that  has 
been  yet  found  of  proneness  to  an  extensive  or  general  fatty  degenera- 
tion of  the  tissues.  It  is  not,  indeed,  an  infallible  sign  thereof;  for 
there  are  cases  in  which  it  exists  Avith  clear  evidences  of  vigor  in  the 
nutrition  of  the  rest  of  the  body  ;  and  there  are  others  in  which  its 
early  occurrence  is  due  to  defective  nutrition  consequent  on  purely 
local  causes,  such  as  inflammatory  afi"ections  of  the  choroid,  or  other 
parts  of  the  eye :  but,  allowing  for  these  exceptions,  it  appears  to  be 

*  The  Editor  can  speak  from  his  own  observations  of  the  existence  in  great  numbers  oi 
minute  corpuscles  between  the  fibres  of  the  white  substance  of  the  different  divisions  of  the 
encephalon,  which  corpuscles  evidently  belong  to  and  form  a  part  of  the  delicate  inter- 
mediate nerve  connective  tissue  or  neuroglia.  The  great  abundance  of  these  corpuscles  not 
only  supplies  a  sufficient  source  for  the  production  of  granule-cells,  but  also  for  those  forma- 
tions of  the  corpuscles  of  pus,  cancer,  and  tubercle,  which  are  occasionally  met  with  in  the 
midst  of  the  white  substance  of  the  great  nerve  centres.  For  a  fuller  exposition  of  the 
theory  of  the  formation  of  such  corpuscles  from  pre-existing  tissue  elements,  the  Editor  may 
refer  to  a  lecture  which  he  delivered  before  the  Royal  College  of  Surgeons  of  Edinburgh, 
February  27,  and  which  is  published  in  the  Edinburgh  Monthly  Medical  Journal, 
April,  1863. 

■f  Observations  on  the  Arcus  senilis,  in  the  Lancet,  1850  and  1851. 

j   Especially  Drs.  Quain,  Williams  and  Virchow  (Archiv,  B.  iv,  288). 


EEPAIE,    ETC.     OF    INJURED    AND    LOST    PARTS,  119 

the  surest,  as  well  as  the  most  visible,  sign  and  measure  of  those  pri- 
mary degenerations  which  it  has  been  the  chief  object  of  the  last  two 
lectures  to  describe.* 


LECTUKE    YIL 

GENERAL   CONSIDERATIONS    ON  THE    REPAIR    AND    REPRODUCTION    OF 
INJURED    AND    LOST    PARTS. 

Among  the  general  considerations  that  may  be  suggested  by  the  pre- 
ceding lectures,  none,  perhaps,  is' more  worthy  of  earnest  thought,  than 
that  of  the  capacity  of  adaptation  to  the  variety  of  their  circumstances, 
which  is  displayed  by  the  several  parts  of  the  body.  Each  part  may 
be  said  to  be  conformed,  in  its  first  construction,  to  a  certain  standard 
of  measure,  weight,  and  power,  by  which  standard  it  is  adjusted  to  the 
other  parts  of  the  whole  organism.  The  first  perfection  of  the  economy 
is  in  the  justness  with  which  its  several  parts  are  thus  balanced  in  their 
powers  ;  and  the  mutual  adaptation  thus  established  is  continued,  in  or- 
dinary life,  by  the  nutrition  of  each  part  being  regulated  according  to  a 
law  of  direct  proportion  to  the  quantity  of  work  that  each  discharges. 

*  The  degenerations  of  organs  not  described  in  the  lectures,  and  the  authorities  not 
already  quoted,  may  be  studied  by  the  following  references : 

Arteries,  Testicles,  Lungs,  and  Liver :  Gulliver,  in  Med.  Chir.  Trans.,  xxvi,  p.  86. 

Liver:  BoM^man,  in  Lancet,  1841-2,  vol.  i,  p.  560. 

Kidney:  Johnson  in  Med.  Chir.  Trans,  xxix,  p.  1;  with  Appendix,  in  xxx,  p.  182;  Si- 
mon, in  Med.  Chir.  Trans.,  xxx,  p.  141 ;  Virchow,  in  his  Archiv,  B.  iv,  p.  264.  et  seq. ;  and 
Gairdner,  Pathology  of  the  Kidney,  Edinb.,  1848. 

Colorless  blood-cells,  various  Epithelial  cells,  Cartilage-corpuscles,  Nerve-cells :  Virchow, 
in  his  Archiv,  i,  p.  144,  et  seq. 

Lungs:  Rainey,  in  Med.  Chir.  Trans.,  vol.  xxxi,  p.  297. 

Placenta :  Barnes,  in  Med.  Chir.  Trans.,  xxxiv  and  xxxvi,  and  Druitt,  Med.  Chir.  Trans., 
vol.  xxxvi. 

Placenta,  Decidua,  and  other  tissues  of  the  uterus,  as  well  as  the  Muscular:  Kilian,  as 
quoted  at  p.  131. 

Cartilage:  Redfern,  "  Anormal  Nutrition  in  the  Articular  Cartilages,"  1850;  and  Virchow, 
in  his  Archiv,  B.  iv,  p.  289.     C.  0.  Weber,  Virchow's  Archiv,  B.  xiii,  1858. 

Numerous  calcareous  degenerations:  Dusseau.  Het  Beenweefsel  en  Verbeeningen,  Am- 
sterdam, 1850. 

The  Transactions  of  the  Pathological  Society  of  London  abound  in  records  of  cases  of  fatty 
and  calcareous  degenerations  of  and  in  the  different  textures. 

Pigmental  degenerations:  Virchow,  in  his  Archiv,  B.  i. 

Prostatic  Concretions:  Hassall,  Microscopic  Anatomy.      Wedl,  Pathological  Histology. 

Amyloid  Degeneration  :  Pagenstecher  Ueber  die  Amyloide  Degeneration.  Wiirzburg, 
1858.  FOrster,  Atlas  der  Path.  Anat.,  1859.  Rouget  in  Brown-Sequard's  Jal.  de  la  Phys. 
Jan.,  1859.  T.  G.  Stewart,  On  the  Waxy  or  Amyloid  Degeneration  of  the  Kidney.  Ed. 
Med.  Jal.,  1861. 

The  chief  general  histories  of  degenerations  are  by  Rokitansky,  Pathol.  Anat. ;  C.  J.  B. 
Williams,  Principles  of  Medicine;  and  Virchow,  in  the  places  cited  above,  and  in  his 
Archiv,  B.  iv,  p.  394. 

The  degenerations  of  products  of  disease  will  be  described  in  future  lectures. 


120        GENERAL     CONSIDERATIONS     ON    THE    REPAIR    AND 

But  when  tlie  external  conditions  of  life  vary,  and  require  for  the  main- 
tenance of  health,  varying  amounts  of  function  to  be  discharged  by  one 
or  more  parts ;  and,  still  more,  when  disease  disturbs  the  functional 
relations  of  any  part  to  the  rest ;  then  each  part  displays  a  capacity  of 
adaptation  to  the  new  conditions  in  which  it  is  placed :  each  can  assume 
a  less  or  greater  size  and  weight ;  each  can  acquire  a  ^less  or  more 
powerful  tissue ;  each  can  thus  rise  above,  or  descend  below,  its  stan- 
dard of  power. 

This  capacity  of  adaptation  is  shown  in  a  yet  more  remarkable  man- 
ner in  the  recovery  of  parts  from  the  effects  of  injuries  and  diseases.  It 
is  surely  only  because  it  is  so  familiar,  that  we  think  lightly,  if  at  all,  of 
the  fact  that  living  bodies  are  capable  of  repairing  the  effects  of  injury, 
and  that  in  this  capacity  they  prove  themselves  adapted  for  events  of 
which  it  is  not  certain  whether  they  will  ever  occur  to  them.  The 
exact  fitness  of  every  part  of  a  living  body  for  its  present  oflBce,  not  as 
an  independent  agent,  but  as  one  whose  work  must  be  done  in  due  pro- 
portion with  many  others  concurring  in  operation  with  it,  is  a  very 
marvellous  thing ;  but  it  seems  much  more  so,  that  in  the  embryo,  each 
of  these  parts  was  made  fit  for  offices  and  relations  that  were  then 
future  :  and  yet  more  marvellous  than  all  it  seems,  that  each  of  them 
should  still  have  capacity  for  action  in  events  that  are  not  only  future, 
but  uncertain  ;  that  are  indeed  possible,  yet  are  in  only  so  low  a  degree 
probable,  that  if  ever  they  happen  they  will  be  called  accidents. 

Let  us  have  always  in  mind  this  adaptation  of  the  living  body  to  future 
probabilities,  while  we  consider  the  physiology  of  repair.  If  it  be  fairly 
weighed,  every  part  of  the  process  of  repair  will  be  an  argument  of 
divine  design  ;  and  such  an  argument  as  cannot  be  impugned  by  the  sus- 
picion that  the  events  among  which  each  living  thing  is  cast  have  deter- 
mined its  adaptation  to  them  :  for  all  the  adaptations  here  noted  prove 
capacities  for  things  future,  and  only  not  improbable. 

And  let  us  also  keep  in  view  how  the  reparative  processes  may  illus- 
trate the  laws  of  ordinary  nutrition ;  and  especially  observe  that  they 
furnish  evidence  of  the  nature  of  the  formative  force  exercised  in  the 
complete  organism.  I  mentioned  in  a  former  lecture  (p.  61)  that,  in 
many  instances  of  repair  and  reproduction,  the  formation  of  the  new 
replacing  structures  cannot  be  ascribed  to  an  assimilative  force,  or  to 
the  development  of  tissue-germs  derived  from  the  injured  or  lost  parts. 
The  completeness  of  repair  after  injury,  and  the  extent  to  which  it  is 
sometimes  accomplished,  become  thus  most  striking  evidences  of  the 
principle  that  the  formative  force,  and  those  that  co-operate  with  it,  are, 
in  the  completed  organism,  the  same  and  continuous  with  those  which 
actuated  the  formation  of  the  original  tissues,  in  the  development  of  the 
germ  and  embryo.  There  is  in  every  considerable  process  of  repair  a 
re-making  of  a  part :  and  the  new  materials  assume  the  specific  form  and 
composition  of  the  part  that  they  replace,  through  the  operation  of  no 
other,  or  otherwise  directed,  force,  than  that  through  which  that  part 


REPRODUCTION     OF    INJURED    AND    LOST     PARTS.         121 

was  first  made.  For,  in  all  grave  injuries  and  diseases,  the  parts  that 
might  serve  as  models  for  the  repairing  materials  to  be  assimilated  to, 
or  as  tissue-germs  to  develop  new  structures,  are  lost  or  spoiled ;  jet 
the  effects  of  such  injury  and  disease  are  recovered  from,  and  the  right 
specific  form  and  composition  are  regained.  In  all  such  cases,  the  re- 
produced parts  are  formed,  not  according  to  any  present  model,  but  ac- 
cording to  the  appropriate  specific  form  ;  and  often  with  a  more  strikingly 
evident  design  towards  that  form  as  an  end  or  purpose,  than  we  can 
discern  in  the  natural  construction  of  the  body. 

Moreover,  it  will  be  observed  in  the  instances  of  repair  of  injury, 
even  more  plainly  than  in  the  maintenance  of  the  body  in  the  successive 
ordinary  stages  of  its  life,  that  the  law  of  formation  is  at  each  period  of 
life  the  same  :  that  every  part  is  formed  after  the  same  method  as  was 
observed  in  the  corresponding  part  of  the  parent  at  the  same  period  of 
life.  Thus,  when,  in  an  adult  animal,  a  part  is  reproduced  after  injury 
or  removal,  it  is  made  in  conformity,  not  with  that  condition  which  was 
proper  to  it  when  it  was  first  formed,  or  in  its  infantile  life,  but  with 
that  which  is  proper  according  to  the  time  of  life  in  which  it  is  repro- 
duced ;  proper,  because  like  that  which  the  similar  part  had,  at  the 
same  time  of  life,  in  members  of  former  generations.  In  the  reproduc- 
tion of  the  foot  or  the  tail  of  the  lizard,  they  grow,  as  it  were,  at  once 
into  the  full  dimensions  proper  to  the  part,  according  to  the  age  of  the 
individual.  Spallanzani  expressly  mentions  this :  that  when  a  leg  is 
cut  from  a  full-grown  salamander,  the  new  leg  and  foot  are  developed, 
as  far  as  form  and  structure  are  concerned,  just  as  those  of  the  larva 
were  ;  but  as  to  size,  they  from  the  beginning  grow  and  are  developed 
to  the  proper  dimensions  of  the  adult.  The  power,  therefore,  by  which 
this  reproduction  is  accomplished,  would  seem  to  be,  not  the  mere  revival 
of  one  which,  after  perfecting  the  body,  had  lapsed  into  a  dormant  state, 
but  the  self-same  power  which,  before  the  removal  of  the  limb,  was 
occupied  in  its  maintenance  by  the  continual  mutation  of  its  particles, 
and  is  now  engaged,  with  more  energy,  in  the  reconstruction  of  the 
whole. 

The  ability  to  repair  the  damages  sustained  by  injury,  and  to  repro- 
duce lost  parts,  appears  to  belong,  in  some  measure,  to  all  bodies  that 
have  definite  form  and  construction.  It  is  not  an  exclusive  property 
of  living  beings  ;  for  even  crystals  will  repair  themselves  when,  after 
pieces  have  been  broken  from  them,  they  are  placed  in  the  same  condi- 
tions in  which  they  were  first  formed. 

The  diagram  (Fig.  10)  represents  a  series  of  casts  made  from  a  crys- 
tal with  which  I  imitated  the  experiments  of  Jordan.*  A  large  piece 
was  broken  off  an  octohedral  crystal  of  alum  (a).  Before  the  fracture 
it  was  perfect  in  its  form,  except  at  one  small  pit  on  its  surface,  where 

*  Milller's  Archiv,  1842,  p.  46, 
9 


122        GENERAL    CONSIDERATIONS     ON    THE    REPAIR    AND 

it  had  what  (writing  of  animal  physiology)  might  be  called  a  congenital 
defect.  Thus  broken  (b)  it  was  placed  again  in  the  solution  in  which 
it  had  been  formed,  and  after  a  few  days  its  injury  was  so  far  repaired 
as  it  appears  in  the  figure  (c).     The  whole  crystal  had  increased,  but 


rig.  10. 


.-'/'  V-v 


A. 


B. 


C. 


the  increase  on  its  broken  surface  was  proportionally  so  much  greater 
than  on  any  other,  that  the  perfect  octohedral  form  was  nearly  regained. 
The  little  congenital  defect,  also,  was  completely  healed.  In  a  few 
days  more  the  whole  crystal  would  have  been  as  if  it  had  suffered  no 
injury. 

I  know  not  what  amount  of  mutual  illustration,  if  any,  the  repair  of 
crystals  and  of  living  bodies  may  afford  ;  but,  in  any  case,  we  may  trace 
here  something  like  a  universal  property  of  bodies  that  are  naturally 
and  orderly  constructed  :  all,  in  favorable  circumstances,  can  repair  at 
least  some  of  the  damages  to  which  they  are  liable  from  the  violence  of 
external  forces. 

But,  to  speak  only  of  the  repair  and  reproduction  that  occur  in  the 
several  orders  of  the  animal  kingdom :  among  these  they  exist  in  sin- 
gularly different  degrees,  and  in  such  as  can  be  only  partially  included 
in  rules  or  general  expressions.  The  general  statement  sometimes 
made,  that  the  reparative  power  in  each  species  bears  an  inverse  ratio 
to  its  position  in  the  scale  of  animal  life,  is  certainly  not  proved ;  and 
many  instances  are  contrary  to  it :  such  as  the  great  reparative  power 
possessed  by  the  Triton  and  other  lizards,  and  the  apparently  complete 
absence  of  it  in  the  perfect  insects.  Rather,  the  general  rule  which 
we  may  expect  to  find  true,  and  for  which  there  is  already  much  evi- 
dence, may  be  that  the  reparative  power  bears  an  inverse  proportion  to 
the  amount  of  power  consumed  in  the  development  and  growth  of  the 
individual,  and  in  its  maintenance  in  the  perfect  state. 

Our  ideas  of  the  consumption  of  power  in  the  organization  of  matter, 
are,  perhaps  unavoidably,  very  vague :  yet  are  there  facts  enough  to 
prove  that  the  power  which  can  be  exercised  in  a  germ  is  limited,  so 
that  the  capacity  of  assuming  the  specific  organic  form  cannot  be  com- 
municated to  an  indefinite  quantity  of  matter ;  and  there  are  also  enough 
to  justify  the  expression,  that  the  power,  thus  limited,  is  in  some  mea- 
sure consumed,  1st,  in  the  development  of  every  new  structure,  and. 


REPRODUCTION    OF    IXJURED.AXD     LOST     PARTS.         123 

2dly,  in  a  less  measure,  in  the  growth  and  maintenance  of  those  already 
formed. 

Thus,  first,  it  appears  constantly  true,  that  the  reparative  power  is 
greater  in  all  parts  of  the  young  than  in  those  of  the  older  individuals 
of  all  species.  Even  when  we  compare  individuals  that  have  all  at- 
tained their  highest  development  and  growth,  this  rule  seems  to  be 
true.  We  know  it  from  general  observations  of  the  results  of  similar 
injuries  and  diseases  in  persons  of  different  ages  :  numerous  as  the  ex- 
ceptions may  be,  the  general  rule  seems  true.  And  it  is  yet  more  evi- 
dently proved  in  the  case  of  some  lower  animals.  Spallanzani  men- 
tions it  in  regard  to  the  reproduction  of  the  tail  of  the  tadpole.  The 
quickness  with  which  the  work  of  reproduction  is  both  begun  and  per- 
fected was  always,  in  his  experiments,  in  an  inverse  ratio  to  the  age. 
He  says  the  same  for  the  reproduction  of  legs  of  salamanders  ;  and  it 
is  only  in  the  young,  among  frogs  and  toads,  that  any  reproduction  of 
the  limbs  will  take  place.  So,  too,  in  experiments  on  the  repair  of 
fractures,  the  union  of  tendons  and  the  like,  in  the  mammalia,  one  may 
see  abundant  evidence  that  the  vigor  and  celerity  of  the  process  are  in 
an  inverse  proportion  to  the  animal's  age.  There  is,  indeed,  some 
reason  to  believe,  that  in  the  very  early  period  of  embryonic  life,  a 
true  reproduction  of  parts  of  limbs  may  take  place  even  in  the  human 
species.  Not  to  speak  of  the  possibility  that  supernumerary  members 
may  be  formed  in  consequence  of  accidental  fission  of  the  budding 
limbs  of  the  embryo,  there  are  cases  in  which  fingers  are  found  on  the 
stumps  of  arms  in  such  circumstances  as  justify  the  belief,  that  after  a 
limb  had  been  accidentally  amputated  in  the  uterus,  these  had  been 
produced  on  its  remaining  portion.* 

All  these  facts  agree  well  with  the  belief  that  the  formative  power  is 
gradually  diminished  in  the  acts  of  organizing  matter  for  the  mainte- 
nance of  the  body  ;  and  the  difference  between  the  completeness  of  re- 
pair in  children  and  that  in  adults  appears  so  much  greater  than  the 
difference  in  adults  of  different  ages,  that  it  is  probable  the  formative 
power  is  more  diminished  by  growth  than  by  mere  maintenance. 

But,  secondly,  it  seems  that  the  capacity  for  the  repair  or  repro- 
duction of  injured  parts  is  much  more  diminished  by  development,  than 
by  growth  or  maintenance  of  the  body;  i.  e.,  much  more  by  those  trans- 
formations of  parts  by  which  they  become  fitted  for  higher  offices,  than 
by  the  multiplication  or  maintenance  of  those  that  are  already  perfect 
in  their  kind  and  function.  In  other  words,  to  improve  a  part  requires 
more,  and  more  perfect,  formative  power,  than  to  increase  it  does. 

This,  as  a  general  principle,  is  exemplified  in  many  instances.  In 
the  greater  part  of  congenital  malformations  we  find  arrest  of  develop- 
ment, but  no  hindrance  of  growth ;  as  a  heart,  in  which  a  septum  fails 
to  be  developed,  yet  grows  to  its  full  bulk.     If  tadpoles  be  excluded 

*  See  a  paper  by  Dr.  Simpson,  in  tlie  London  and  Edinburgh  Monthly  Journal,  Jan.,  1848. 


124        GENERAL    C  0  N  S  ID  E  E  A  TI  0  N  S     ON    THE     EEPAIR    AND 

from  due  light  and  heat,  their  development  will  be  much  retarded,  but 
their  growth  will  be  less  checked :  in  other  words,  the  conditions  of  nu- 
trition which  are  enough  for  growth  are  not  sufficient  for  development. 
When  a  part  is,  without  disease,  unduly  supplied  with  blood,  it  may 
grow  beyond  its  normal  size,  but  it  is  never  developed  beyond  its  nor- 
mal structure  :  that  which  is  sufficient  for  increase  of  growth,  is  not 
enough  for  an  advance  in  development.  Again,  in  the  miscalled  culti- 
vation and  improvement  of  flowers,  growth  is  increased,  but  develop- 
ment is  hindered  ;  and  an  excess  of  colored  leaves  is  formed,  instead  of 
the  due  number  of  male  and  female  organs.  In  an  old  ulcer  or  a  sinus, 
cells  may  be  continually  reproduced,  maintaining  or  even  increasing 
the  granulations,  yet  they  will  not  develop  themselves  into  connective 
tissue  and  cuticle  for  the  healing  of  the  part.  And  so,  lastly,  even 
when  repair  and  reproduction  have  gone  far  towards  their  ultimate 
achievement,  that  which  takes  a  longer  time,  and  oftener  fails,  is  the 
improvement,  the  perfecting  of  the  new  material,  by  its  final  develop- 
ment. This  is  observed  in  all  cases  of  reproduced  limbs,  and  even  in 
ordinary  scars. 

These  facts  (and  there  are  many  others  like  them)  seem  to  justify  the 
expression  that,  not  only  more  favorable  conditions,  but  also  a  larger 
amount  of  organizing  force,  are  expended  in  development  than  in  growth, 
or  maintenance ;  and  that  the  reparative  power  bears  an  inverse  ratio 
to  the  amount  of  force  already  expended  in  these  processes.  If  it  be 
so,  we  might  expect  that  in  each  species,  in  its  perfect  state,  the  repara- 
tive power  might  be  measured  by  the  degree  of  likeness  between  the  em- 
bryonic and  the  perfect  form,  structure,  and  composition. 

There  are  many  apparent  exceptions  to  such  a  rule,  especially  in  the 
Asteridse,  which,  though  constructed  through  manifold  metamorphoses, 
have  great  capacity  of  restoring  detached  rays  ;*  yet  it  is  consistent 
with  such  a  rule  that  the  highest  amount  of  reparative  power  exists  in 
those  lowest  polypes  in  which  the  materials  of  the  germ-mass  are  least 
transformed,  but  are  multiplied,  and,  as  it  were,  grouped  into  the  shape 
of  their  bodies.  In  the  Hydra  viridis,  and  Hydra  fusca,  it  seems  lite- 
rally true  that  any  minute  portion  derived  from  the  germ-mass  may, 
after  being  separated  from  the  perfect  body,  reproduce  the  perfect 
form.  This  is  the  general  truth  of  the  numerous  experiments  performed 
on  Hydrse  by  Trembley,  Hoesel,  and  others.  They  have  been  so  often 
quoted,  that  I  need  not  do  more  than  mention  the  greatest  instances  of 
reproductive  power  that  they  showed, 

Trembley  cut  a  Hydra  into  four  pieces :  each  became  a  perfect  Hy- 
dra ;  and,  while  they  were  growing  he  cut  each  of  these  four  into  two 
or  three.  These  fractions  of  the  quarters  being  on  their  way  to  become 
perfect,  he  again  divided  these,  and  thus  he  went  on,  till  from  the  one 
Hydra  he  obtained  fifty.     All  these  became  perfect ;  he  kept  many  of 

*  A  good  account  of  the  mode  of  reproduction  of  lost  rays  in  the  Asteridje  may  be  found, 
by  Dr.  H.  S.  Wilson,  in  the  Trans.  Linn£?an  Soc.  1860. 


REPRODUCTION     OF    INJURED     AND     LOST     PARTS.         125 

them  for  more  than  two  years,  and  they  multiplied  by  their  natural 
gemmation  just  as  much  as  others  that  had  never  been  divided.  Again, 
he  cut  similar  polypes  longitudinally,  and  in  an  hour  or  less  each  half 
had  rolled  itself,  and  seamed  up  its  cut  edges,  so  as  to  be  a  perfect 
Hydra.  He  split  them  into  four ;  he  quartered  them ;  he  cut  them 
into  as  many  pieces  as  he  could ;  and  nearly  every  piece  became  a 
perfect  Hydra.  He  slit  one  into  seven  pieces,  leaving  them  all  con- 
nected by  the  tail,  and  the  Hydra  became  seven-headed,  and  he  saw  all 
the  heads  eating  at  the  same  time.  He  cut  off  the  seven  heads,  and, 
Hydra-like,  they  sprang  forth  again.  And  even  the  fabulist  dared  not 
invent  such  a  prodigy  as  the  naturalist  now  saw.  The  heads  of  the 
Lernsean  Hydra  perished  after  excision  :  the  heads  of  this  Hydra  grew 
for  themselves  bodies,  and  multiplied  with  as  much  vigor  as  their 
parent-trunk. 

Now  these  instances  may  suffice  to  show  not  only  the  great  capacity 
of  reproduction  in  the  lowest  polypes,  but,  also,  that  in  them  the  pro- 
cess of  reproduction  after  injury  confounds  itself  with  that  of  their 
natural  generation  by  gemmation,  or,  as  it  probably  more  rarely  hap- 
pens, by  spontaneous  fission.  We  cannot  discern  a  distinction  between 
them ;  and  there  are  facts  which  seem  to  prove  the  identity  of  the 
power  which  operates  in  both.  Thus,  in  both  alike,  the  formative 
power  is  limited  according  to  the  specific  characters  of  the  Hydra ;  im- 
mense as  the  power  of  increase  is  which  may  be  brought  into  action  by 
the  mutilations  of  the  Hydra,  yet  that  power  cannot  be  made  to  pro- 
duce a  Hydra  of  much  more  than  ordinary  size,  or  to  raise  one  above 
its  ordinary  specific  characters.  And,  again,  the  identity  of  the  power 
is  shown  in  this,  that  the  natural  act  of  gemmation  retards  that  of  re- 
production after  injury.  Trembley  particularly  observes,  that  when  a 
Hydra,  from  which  the  head  and  tentacula  had  been  cut  off,  gemmated, 
the  reproduction  of  the  tentacula  was  retarded  soon'  after  the  gemmule 
appeared. 

Many  other  species  manifest  this  coincidence  of  the  power  of  propa- 
gating by  gemmation  or  fission,  and  of  reproducing  large  portions  of 
the  body,  and  even  of  reconstructing,  from  fragments,  the  whole  body. 
Among  them,  as  chief  examples,  are  the  Actiniae,  which,  after  bisection 
form  two  individuals ;  and  the  Holothurias,  which,  as  Sir  J.  G.  Dalyell 
has  observed,  when  hurt  or  handled,  will  eject  all  their  viscera,  leaving 
their  body  a  mere  empty  sac,  and  yet  in  three  or  four  months  will  have 
all  their  viscera  regenerated.  And  to  these  may  be  added,  from  among 
the  Annelida,  the  young  Nereids,  and  those  species  of  Nais,  on  which 
Bonnet,  Spallanzani,  and  others,  made  their  experiments  ;  experiments 
of  which  the  climax  seemed  to  be  achieved  when  a  Nais  was  cut  by 
M.  Lyonnet  into  thirty  or  forty  separate  pieces,  and  there  were  pro- 
duced from  those  fragments  as  many  perfect  individuals. 

Among  the  instances  of  greatest  capacity  of  repair,  some  observed 


126 


GENERAL  CONSIDERATIONS  ON  THE  REPAIR  AND 


bj  Sir  J.  G.  Dalyell*  seem  to  illustrate,  in  a  remarkable  manner,  the 
general  laws  of  the  reparative  processes  in  even  the  higher  animals. 
In  Actinia  lacerata,  Dalyell  observed  that  numerous  ragged  processes 
were  put  forth  from  the  whole  circumference  of  the  disc,  which  were 
gradually  torn  off,  and  became  afterwards  developed  into  minute 
Actiniae.  Observations  of  a  similar  nature  have  been  made  by  Dr. 
Strethill  Wrightf  with  regard  to  x\.ctinia  dianthus.  The  latter  author, 
after  noting  the  process  of  natural  fissure  in  Actinia  dianthus,  pro- 
duced similar  phenomena  by  artificial  fissure.  From  the  foot  of  a 
specimen  of  this  Actinia,  which  showed  no  tendency  to  natural  genera- 
tion, he  detached  a  very  minute  portion,  which  by  careful  examination 
he  satisfied  himself  contained  no  ovum  or  structure  difi"erent  from  the 
ordinary  tissue  of  the  wall  of  the  body.  This  minute  portion  in  three 
weeks  became  a  perfect  Actinia.  From  this  product  of  artificial  fissure, 
again,  he  divided  other  portions,  which  also  in  time  developed  into 
perfect  animals.  All  that  appeared  to  be  necessary  to  this  process  of 
multiplication  being  the  existence  in  the  severed  part  of  the  three 
elemental  tissues  of  the  body, — the  dermal,  muscular  and  mucous. 

In   the  Hydra  tuba,  the  species  in  which  Dalyell  traced  that  mar- 
vellous development  into  Medusae,  he  found  that  when  cut  in  halves, 

rig..  11. 


c. 


each  half  m^y  regain  the  perfect  form  ;  but  this  perfect  form  is  regained 
only  very  slowly,  and,  as  it  were,  by  a  gradual  improvement  of  parts 
that  are  at  first  ill-formed.  The  sketch,  copied  from  his  plate,  shows 
the  succession  of  forms  marking  these  stages  of  improvement  in  the 
"distal  part  of  a  Hydra  tuba  (a),  Avhich  had  been  detached  by  cutting 
through  the  animal  with  a  pair  of  scissors. 

Through  these  forms,  commencing  at  B,  into  which  the  distal  or  free 
half  of  A  was  first  changed,  the  perfect  state  of  a  Hydra  was  at  length 
reached ;  as  at  C.  The  obliteration  of  the  old  tentacles,  together  with 
the  changes  which  take  place  in  the  new  before  they  assume  their  fully 
developed  form,  may  possibly  be  explained  (as  he  suggests)  by  the  mu- 


*  Rare  and  Remarkable  Animals  of  Scotland,  vol.  i,  pi.  14;  vol.  ii,  p.  230,  pi.  47. 
f  Proc.  Roy.  Phys.  Soc.  Ed.,  vol.  i,  161. 


REPRODUCTION    OF    INJURED    AND     LOST    PARTS. 


127 


Fig.  12. 


tilation  having  disturbed  the  progress  of  the  Hydra  in  its  development 
of  young  Medusae  ;  for  the  experiment 
was  made  in  March,  nearly  at  the  time 
when  the  series  of  changes  should  have 
commenced.  But,  if  I  may  venture 
not  to  accept  the  suggestion  of  so  ad- 
mirable an  observer,  I  should  suspect 
rather  that  this  is  an  instance  of  gra- 
dual recovery  of  perfection,  such  as  we 
see  more  generally  in  the  repair  of  in- 
juries and  diseases  in  the  higher  ani- 
mals. 

He  has  noticed  something  of  the 
same  kind,  and  more  definite,  in  the 
Tubularia  indivisa  (PL  iv)  ;  one  of  his 
experiments  on  which  is  illustrated  by 
Fig.  12.  A  fine  specimen  was  cut  near 
its  root,  and  after  the  natural  fall  of  its 
head,  the  summit  of  its  stem  was  cloven. 
An  imperfect  head  was  first  produced, 
at  right  angles  to  the  stem,  from  one 
portion  of  the  cleft  (a)  ;  after  its  fall,      a.  b.  c. 

another  and  more  nearly  perfect   one 

was  regenerated,  and,  as  it  grew,  improved  yet  more  (b).  A  third  ap- 
peared, and  then  a  fourth,  which  was  yet  more  nearly  perfect,  though 
the  stem  was  thick,  and  the  tentacula  imperfect.  The  cleft  was  almost 
healed ;  and  now  a  fifth  head  was  formed,  quite  perfect  (c)  ;  and  after 
it,  as  perfectly,  a  sixth  and  a  seventh  head.  All  these  were  produced 
in  fifteen  months. 

The  lower  half  of  this  specimen  had  been  cut  ofi"  four  months  after 
the  separation  of  the  stem.  Its  upper  end  bore — first,  an  abortive 
head ;  then,  secondly,  one  which  advanced  further  in  development ;  a 
third,  much  better  ;  and  then,  in  succession,  other  four,  which  were  all 
well  formed. 

The  upper  portion  of  this  lower  half  of  the  stem  now  showing  signs  of 
decay,  a  portion  was  cut  from  its  lowest  part,  and  further  manifested  the 
reproductive  power  of  the  stem  ;  for  three  heads  were  produced  from  the 
upper  end  of  the  piece  cut  off,  and  four  from  the  lower  end  of  the  upper 
piece  which  had  seemed  to  be  decaying.  In  550  days  this  specimen 
had  grown  twenty-two  heads, 

Now,  I  cannot  but  think  that  we  have,  in  these  instances  of  gradual 
recovery  from  the  effects  of  injury,  a  type  of  that  gradual  return  to  the 
perfect  form  and  composition  which  is  noticed  in  the  higher  animals. 
Our  theory  of  the  process  of  nutrition  leads  us  to  believe  that,  in  the 
constant  mutation  of  particles  in  nutrition,  those  elements  or  those 
molecules  of  the  blood,  or  of  any  structure,  that  have  been  altered  by 


128   GENERAL  CONSIDERATIONS  ON  THE  REPAIR  AND 

disease,  in  due  time  degenerate  or  die,  and  are  cast  off  or  absorbed ;  and 
that  those  which  next  succeed  to  them  partake,  through  the  assimilative 
force,  of  the  same  morbid  character  ;  but  that,  every  time  of  renewal, 
the  new  particles  approach  a  step  nearer  to  the  perfect  state.  Thus,  as  it 
were,  each  generation  of  new  particles  is  more  nearly  perfect,  till  all  the 
effects  of  injury  or  the  disease  are  quite  obliterated.  Surely,  in  the 
gradual  recovery  of  perfection  by  these  polypes,  we  have  an  apt  illus- 
tration of  the  theory  ;  one  which  almost  proves  its  justice. 

The  power  of  reconstructing  a  whole  and  perfect  body,  by  the  de- 
velopment of  a  fragment,  is  probably  limited  to  the  species  that  can 
propagate  by  spontaneous  fission  or  gemmation,  or  that  increase  their 
size,  as  some  of  the  Annelida  do,  by  the  successive  addition  of  rings 
that  are  developed  after  the  manner  of  gemmules  from  those  that  pre- 
cede them.  Where  this  power  is  not  possessed,  there,  whatever  be  the 
position  of  the  species  in  the  animal  scale,  the  reparative  power  appears 
to  be  limited  to  the  reproduction  of  lost  members ;  such  as  legs,  claws, 
a  part  of  the  body,  the  head,  an  eye,  the  tail,  and  the  like.  Within  this 
limit,  the  rule  seems  again  to  hold  good,  that  the  amount  of  reparative 
power  is  in  an  inverse  ratio  to  that  of  the  development,  or  change  of 
structure  and  mode  of  life,  through  which  the  animal  has  passed  in  its 
attainment  of  perfection,  or  on  its  way  thitherward. 

Here,  however,  even  more  than  in  the  former  cases,  we  need,  not 
perhaps  more  experiments,  but  experiments  on  a  larger  number  of 
species.  It  appears  generally  true,  that  the  species  whose  development 
to  the  perfect  state  is  comparatively  simple  and  direct,  have  great  re- 
parative powers;  while  many,  at  least  of  those  in  which  the  develop- 
ment is  with  such  great  changes  of  shape,  structure,  and  mode  of  life, 
as  may  be  called  metamorphosis,  retain  in  their  perfect  state  scarcely 
any  power  for  the  repair  of  losses.  Yet  we  want  more  instances  of 
this  ;  and  especially,  it  were  to  be  wished  that  we  had  the  results  of  ex- 
periments upon  the  lowest  animals  that  pass  through  such  metamor- 
phoses ;  e.  g.  on  the  Hydra  tuba,  not  only  in  its  Hydra  state,  but  in  all 
the  changes  that  succeed,  till  it  attains  its  complete  Medusal  form. 

In  the  absence  of  such  evidence  as  experiments  of  this  kind  might 
furnish,  the  best  examples  of  the  rule  are  furnished  by  the  experiments 
of  Mr.  Newport.  They  show  that  among  the  insects,  the  reparative 
power,  in  the  complete  state,  is  limited  to  the  orders  in  which  that 
state  is  attained  by  comparatively  simple  and  direct  course  of  develop- 
ment ;  as  the  Myriapoda  and  Phasmidse,  and  some  of  the  Orthoptera. 
These  can  reproduce  their  antennae,  and  their  legs,  after  removal  or  mu- 
tilation ;  but  their  power  of  reproduction  diminishes  as  their  develop- 
ment increases.  Even  in  the  Myriapoda,  whose  highest  development 
scarcely  carries  their  external  form  beyond  that  of  the  larvae  of  the 
more  perfect  insects,  such  reparative  power  apparently  ceases,  when, 


EEPE.ODUCTION     OF    INJURED    AND    LOST     PARTS.        129 

after  the  last  casting  of  their  integuments,  their  development  is  com- 
pleted. 

In  the  higher  hexapod  insects,  such  reproduction  has  been  seen  in 
only  the  larval  state  ;  none  of  them,  in  its  perfect  state,  can  reproduce 
an  antenna,  or  any  other  member.  The  Myriapoda,  then,  are,  in  their 
reparative  power,  equal  to  the  larvge  of  the  higher  insects,  and  nearly 
all  the  power  for  formation  which  these  manifest,  appears  to  be  ex- 
hausted in  the  two  later  metamorphoses. 

The  case  is  the  stronger,  as  illustrating  the  expenditure  of  power  in 
metamorphses,  when  the  higher  insects  are  compared  with  the  Arach- 
nida ;  for  in  these,  which  attain  their  perfect  state  through  more  direct 
development,  the  reparative  power  remains  equal  to  the  reproduction  of 
limbs  and  attennse. "  A  yet  stronger  contrast  is  presented  between  the 
higher  insects  and  the  several  species  of  salamander,  in  which  so  pro- 
fuse a  reproduction  of  the  limbs  has  been  observed  ;  for  though  they  be 
much  higher  in  the  scale  of  animal  life,  yet  the  amount  of  change  in 
external  form  and  habits  of  life,  through  which  they  pass,  in  their  de- 
velopment from  the  embryo  to  the  perfect  state,  appears  less  than  that 
accomplished  in  the  metamorphoses  of  insects. 

Many  instances,  besides  those  which  I  have  cited,  appear  to  support 
this  rule,  that  the  reparative  power,  in  each  perfect  species,  whether  it 
be  higher  or  lower  in  the  scale,  is  in  an  inverse  proportion  to  the  amount 
of  change  through  which  it  has  passed  in  its  development  from  the  em- 
bryonic to  the  perfect  state.  And  the  deduction  we  may  make  from 
them  is,  that  the  powers  for  development  from  the  embryo  are  identical 
with  those  exercised  for  the  restoration  from  injuries :  in  other  words, 
that  the  powers  are  the  same  by  which  perfection  is  first  achieved,  and 
by  which,  when  lost,  it  is  recovered.* 

This  is,  again,  generally  confirmed  in  the  instances  of  the  Vertebrata ; 
but  of  the  repair  in  these,  or  at  least  in  the  highest  of  them,  I  shall 
have  to  speak-  so  exclusively  in  the  future  lectures,  that  I  will  now  only 
say  that,  in  man  and  other  mammalia,  a  true  reproduction  after  loss  or 
injury  seems  limited  to  three  classes  of  parts  : 

1.  To  those  which  are  formed  entirely  by  nutritive  repetition,  such 
as  the  blood  and  the  epithelia. 

2.  To  those  which  are  of  lowest  organization,  and  (which  seems  of 
more  importance)  of  lowest  chemical  character ;  as  the  gelatinous  tis- 
sues, the  connective,  and  the  bones. 

3.  To  those  which  are  inserted  in  other  tissues,  not  as  essential  to 
their  structure,  but  as  accessories,  as  connecting  or  incorporating  them 
with  the  other  structures  of  vegetative  or  animal  life ;  such  as  nerve- 
fibre  and  bloodvessels. 

With  these  exceptions,  injuries  or  losses  in  the  human  body  are  ca- 
pable of  no  more  than  repair,  in  its  most  limited  sense ;  i.  e.  in  the 

*  Observations  on  the  mode  of  reproduction  of  lost  parts  in  the  Crustacea,  by  H.  D.  S. 
Goodsir,  may  be  found  in  the  Anat.  and  Path.  Observations,  Edinburgh,  1845. 


130   GENERAL  CONSIDERATIONS  ON  THE  REPAIR  AND 

place  of  what  is  lost,  some  lowly  organized  tissue  is  formed,  which  fills 
up  the  breach,  and  suffices  for  the  maintenance  of  a  less  perfect  life. 

I  may  seem  in  this,  as  in  some  earlier  lectures,  to  have  been  discuss- 
ing doctrines  that  can  hardly  be  applicable  to  our  daily  practice,  and 
with  illustrations  drawn  from  objects  in  which  surgeons  may  have  but 
little  interest.  Let  me,  then,  if  only  in  apology,  refer  to  some  of  the 
considerations  which  are  suggested  by  studies  such  as  these.  Let  me, 
first,  express  my  belief  that,  if  we  are  ever  to  escape  from  the  obscuri- 
ties and  uncertainties  of  our  art,  it  must  be  through  the  study  of  those 
highest  laws  of  our  science,  which  are  expressed  in  the  simplest  terms  in 
the  lives  of  the  lowest  orders  of  creation.  It  was  in  the  search  after 
the  mysteries — that  is,  after  the  unknown  highest  laws — of  generation, 
that  the  first  glance  was  gained  of  the  largest  truth  in  physiology, — the 
truth  of  the  development  of  ova  through  partition  and  multiplication  of 
the  embryo-cells.  So  may  the  study  of  the  repair  of  injuries  sustained 
by  the  lowest  polypes  lead  us  to  the  clearer  knowledge  of  that  law,  in 
reliance  upon  which  alone  we  dare  to  practice  our  profession, — the  law, 
that  lost  perfection  may  be  recovered  by  the  operation  of  the  powers  by 
which  it  was  once  achieved.  Already,  in  the  facts  that  I  have  quoted 
from  Sir  J.  Grraham  Dalyell,  we  seem  to  have  the  foreshadowing  of  those 
through  which  the  discovery  may  be  made. 

Then,  let  us  not  overlook  those  admirable  provisions,  which  we  may 
find  in  the  lives  of  all  that  breathe,  against  injuries  that,  but  for  these 
provisions,  would  too  often  bring  them  to  their  end  before  their  appointed 
time,  or  leave  them  mutilated  to  finish  a  painful  and  imperfect  life.  We 
are  not  likely  to  undervalue,  or  to  lose  sight  of,  the  design  of  all  such 
provisions  for  our  own  welfare.  But  we  may  better  appreciate  these, 
if  we  regard  them  as  only  of  the  same  kind  as  those  more  abundantly 
supplied  to  creatures  whom  we  are  apt  to  think  insignificant :  indeed, 
so  abundantly,  that,  as  if  with  a  consciousness  of  the  facility  of  repair, 
self-mutilation  is  commonly  resorted  to  for  the  preservation  of  life. 
When  the  Ophiuradse,  or  any  of  the  brittle  Star-fishes,  break  them- 
selves to  fragments,  and  disappoint  the  grasp  of  the  anxious  naturalist, 
they  probably  only  repeat  Avhat  they  are  instinctively  taught  to  do, 
that  they  may  elude  the  jaws  of  their  more  ravenous  enemies.  But 
death  would  be  much  better  than  such  mutilation,  if  their  rays  could 
not  be  reproduced  almost  as  easily  as  they  can  be  rejected.  The  ex- 
perimentalist, too,  who  cuts  off  one  or  the  other  end  of  any  of  the  An- 
nelida, perhaps  only  puts  them  to  a  necessity  to  which  they  are  liable 
from  the  attacks  of  their  carnivorous  neighbors.  Almost  defenceless, 
and  so  easily  mutilated,  their  condition,  were  it  not  for  their  faculty  of 
reproduction,  might  be  more  deplorable  than  that  of  any  other  creature  ; 
and  even  their  existence  as  species  might  have  been  endangered  long 
ago.  It  would  almost  seem  as  if  the  species  that  have  least  means  of 
escape  or  defence  from  mutilation  were  those  on  which  the  most  ample 


REPEODUCTION     OF    INJURED    AND    LOST    PARTS.        131 

poAver  of  repair  has  been  bestowed  ;  an  admirable  instance,  if  it  be  only 
generally  true,  of  the  beneficence  that  has  provided  for  the  welfare  of 
even  the  least  (as  we  call  them)  of  the  living  world,  with  as  much  care 
as  if  they  were  the  sole  objects  of  the  Divine  regard. 

Lastly,  if  I  may  venture  on  so  high  a  theme,  let  me  suggest  that  the 
instances  of  recovery  from  disease  and  injury  seem  to  be  only  examples 
of  a  law  yet  larger  than  that  within  the  terms  of  which  they  may  be 
comprised  ;  a  law  wider  than  the  grasp  of  science ;  the  law  that  ex- 
presses our  Creator's  will  for  the  recovery  of  all  lost  perfection.  To 
this  train  of  thought  we  are  guided  by  the  remembrance  that  the  healing 
of  the  body  was  ever  chosen  as  the  fittest  emblem  of  His  work,  whose 
true  mission  was  to  raise  man's  fallen  spirit  and  repair  the  injuries  it 
had  sustained  ;  and  that  once,  the  healing  power  was  exerted  in  a  man- 
ner purposely  so  confined  as  to  advance,  like  that  which  we  can  trace, 
by  progressive  stages  to  the  complete  cure.  For  there  was  one,  upon 
whom,  when  the  light  of  Heaven  first  fell,  so  imperfect  was  his  vision, 
that  he  saw  confusedly,  "  men  as  trees  walking  ;"  and  then  by  a 
second  touch  of  the  Divine  Hand,  was  "  restored,  and  saw  every  man 
clearly."  Thus  guided  by  the  brighter  light  of  revelation,  it  may  be 
our  privilege,  while  we  study  the  science  of  our  healing  art,  to  gain  by 
the  illustrations  of  analogy,  a  clearer  insight  into  the  Oneness  of  the 
plan  by  which  things  spiritual  and  corporeal  are  directed.  Even  now, 
we  may  trace  some  analogy  between  the  acts  of  the  body  and  those  of 
man's  intellectual  and  moral  nature.  As  in  the  development  of  the 
germ,  so  in  the  history  of  the  human  spirit,  we  may  discern  a  striving 
after  perfection ;  after  a  perfection,  not  viewed  in  any  present  model 
(for  the  human  model  was  marred  almost  as  soon  as  it  was  formed),  but 
manifested  to  the  enlightened  Reason  in  the  "  Express  Image"  of  the 
"  Father  of  Spirits."  And  so,  whenever,  through  human  frailty,  amid 
the  violences  of  the  world,  and  the  remaining  "  infection  of  our  nature," 
the  Spirit  loses  aught  of  the  perfection  to  which  it  was  once  admitted, 
still  its  implanted  Power  is  ever  urgent  to  repair  the  loss.  The  same 
power,  derived  and  still  renewed  from  the  same  Parent,  working  by  the 
same  appointed  means,  and  to  the  same  end,  restores  the  fallen  spirit 
to  nearly  the  same  perfection  that  it  had  before.  Then,  not  unscarred, 
yet  living — "  fractus  sed  invictus" — the  Spirit  still  feels  its  capacity 
for  a  higher  life,  and  presses  to  its  immortal  destiny.  In  that  destiny  the 
analogy  ends.  We  may  watch  the  body  developing  into  all  its  marvel- 
lous perfection  and  exact  fitness  for  the  purpose  of  its  existence  in  the 
world ;  but,  this  purpose  accomplished,  it  passes  its  meridian,  and  then 
we  trace  it  through  the  gradual  decays  of  life  and  death.  But,  for  the 
human  Spirit,  that  has  passed  the  ordeal  of  this  world,  there  is  no  such 
end.  Emerging  from  its  imprisonment  in  the  body,  it  soars  to  the  ele- 
ment of  its  higher  life  :  there,  in  perpetual  youth,  its  powers  expand,  as 
the  vision  of  the  Infinite  unfolds  before  it ;  there,  in  the  very  presence 
of  its  Model,  its  Parent,  and  the  Spring  of  all  its  power,  it  is  "  like  Him, 
for  it  sees  him  as  He  is." 


132  REPARATIVE  MATERIALS. 


LECTURE  VIIL 

THE    MATERIALS    FOR    THE    REPAIR    OF    INJURIES. 

In  the  present  lecture  I  propose  to  give  a  general  account  of  the 
materials  employed  for  the  repair  of  some  of  the  injuries  inflicted  on 
the  human  body. 

I  hope  I  do  not  err  in  thinking  that  the  most  advantageous  mode  of 
treating  this  subject  will  be  to  confine  myself  to  that  class  of  injuries 
which  may  be  called  visible  breaches  of  continuity ;  such  as  wounds 
and  fractures.  For,  in  regard  to  the  recovery  from  diseases,  our 
knowledge  of  the  efi"ects  of  any  disease  seems,  as  yet,  too  imperfect  for 
us  to  trace  the  stages  by  which  the  morbid  state  reverts  to  that  which 
is  healthy.  We  may  be  sure  it  is  in  conformity  with  the  same  general 
laws  as  those  of  recovery  from  injury,  and  almost  sure  that  it  is  by 
the  gradual  improvement  of  the  particles  that  in  succession  replace 
those  altered  by  disease.  But  the  whole  details  of  the  process  have 
yet  to  be  discovered. 

Even  within  the  narrower  field  of  the  repair  of  breaches  of  con- 
tinuity, I  must  yet  assign  to  myself  a  closer  limit.  A  future  lecture 
will  be  devoted  to  the  healing  of  fractures  ;  in  this,  therefore,  I  shall 
speak  almost  exclusively  of  the  healing  of  divided  soft  parts ;  and  I 
shall  take,  as  the  chief  and  typical  examples,  the  repairs  of  wounds 
made  in  operations.  References  to  the  healing  of  other  injuries  may, 
however,  be  made  by  the  way,  and  for  collateral  illustration. 

Modern  surgery  has  shown  how  right  Mr.  Hunter  was,  when,  in  the 
very  beginning  of  his  discussion  concerning  the  healing  of  injuries,  he 
points  out,  as  a  fundamental  principle,  the  difi"erence  between  those 
two  forms  of  injuries  of  which  one  is  subcutaneous,  the  other  open  to 
the  air.  He  says :  "  The  injuries  done  to  sound  parts  I  shall  divide 
into  two  sorts,  according  to  the  effects  of  the  accident.  The  first  kind 
consists  of  those  in  which  the  injured  parts  do  not  communicate  ex- 
ternally, as  concussions  of  the  whole  body,  or  of  particular  parts, 
strains,  bruises,  and  simple  fractures,  which  form  a  large  division.  The 
second  consists  of  those  which  have  an  external  communication,  com- 
prehending wounds  of  all  kinds  and  compound  fractures."*  And  then, 
he  says,  "  The  injuries  of  the  first  division,  in  which  the  parts  do  not 
communicate  externally,  seldom  inflame ;  while  those  of  the  second 
commonly  both  inflame  and  suppurate." 

In  these  sentences  Mr.  Hunter  has  embodied  the  principle  on  which" 
is  founded  the  whole  practice  of  subcutaneous  surgery ;  a  principle  of 
which,  indeed,  it  seems  hardly  possible  to  exaggerate  the  importance. 

*  Works,  vol.  iii,  p.  240. 


REPARATIVE    MATERIALS.  133 

For,  of  the  two  injuries  inflicted  in  a  wound,  the  mechanical  distur- 
bance of  the  parts,  and  the  exposure  to  the  air  of  those  that  were 
covered,  the  exposure,  if  continued,  is  the  worse.  Both  are  apt  to  ex- 
cite inflammation ;  but  the  exposure  excites  it  most  certainly,  and  in 
the  worse  form ;  i.  e.,  in  the  form  which  most  delays  the  process  of 
repair,  and  which  is  most  apt  to  endanger  life.  Abundant  instances 
of  this  are  shown  in  the  difi"erence  between  a  simple  and  a  compound 
fracture,  though  the  former  may  have  been  produced  by  the  greater 
violence ;  or,  between  a  simple  fracture,  even  with  much  violence,  ex- 
tending into  a  joint,  and  an  open  wound,  never  so  gently  made  into 
one.  Or,  for  parallel  instances,  one  may  cite  the  rarity  of  suppurations 
after  even  extensive  ecchymoses,  and  their  general  occurrence  when 
wounds  are  left  open, 

I  had  frequent  occasion  to  observe  these  diff"erences,  in  a  series  of 
experiments  made  for  the  illustration  of  the  healing  of  divided  muscles 
and  tendons.  Some  of  these  were  divided  through  open  wounds,  and 
some  by  subcutaneous  section  ;  and  the  recital  of  a  single  experiment 
may  afford  a  fair  example  of  the  difference  of  results  that  often  ensued. 
In  the  same  rabbit,  the  tibialis  anticus  and  extensor  longus  digitorum 
were  divided  on  the  right  side  with  a  section  through  the  skin  ;  on  the 
left,  with  a  subcutaneous  section,  through  a  small  opening.  Twelve 
days  afterwards  the  rabbit  was  killed.  The  wound  on  the  left  side  w^as 
well  repaired,  and  with  comparatively  little  trace  of  inflammation  :  the 
gap  on  the  right  was  closed  in  with  a  scab,  and  an  imperfect  scar,  but 
under  these  was  a  large  collection  of  pus,  and  no  trace  of  a  reparative 
process.  The  contrast  is  the  stronger,  because  in  all  these  cases  there 
is,  unavoidably,  more  mechanical  violence  inflicted  in  the  gradual  sub- 
cutaneous division  than  in  the  simple  open  wound.  And,  it  must  be 
added,  that  a  speedy  closure  of  the  external  wound  made  in  an  open 
section  may  bring  the  case  into  more  favorable  conditions  than  those 
of  a  subcutaneous  wound  made  with  more  violence.  This,  also,  I  saw 
in  some  of  the  experiments:  a  clumsy  subcutaneous  division  of  one 
Achilles-tendon  excited  great  inflammation  about  it ;  while  the  open 
section  of  the  other  tendon  in  the  same  rabbit  was  quickly  and  well 
repaired,  if  the  external  wound  had  been  speedily  united,  and  had  suffi- 
ciently soon  converted  the  open  into  a  subcutaneous  injury. 

Still,  what  Mr.  Hunter  said  is  true,  especially  in  wounds  in  our  own 
bodies  :  subcutaneous  wounds  seldom  inflame  ;  open  wounds  generally 
both  inflame  and  suppurate.  It  will  be  a  principal  object  of  this  lec- 
ture to  show  something  like  an  anatomical  reason  for  this  difference,  in 
the  fact  that  the  materials  produced  for  the  repair  of  open  wounds  are 
not  usually  the  same,  or,  at  least,  do  not  develop  themselves  in  the 
same  manner,  as  those  for  the  repair  of  closed  or  subcutaneous  ones. 
The  physiological  and  nearer  reason  is  probably  to  be  discovered  in  the 
influence  of  oxygen  abnormally  admitted  to  the  tissues,  and  producing 


1B4  REPARATIVE     MATERIALS. 

in  them  such  effects  as  are  more   nearly  traced  in  the  phenomena  of 
inflammation,  and  will  be  described  in  future  lectures. 

Before  speaking  of  the  materials  for  repair,  I  must  briefly  state  that 
the  healing  of  open  wounds  may  be  accomplished  by  five  different 
modes  :  namely,  1.  By  immediate  union ;  2.  By  primary  adhesion  ; 
3.  By  granulation ;  4.  By  secondary  adhesion,  or  the  union  of  granu- 
lations ;  5.  By  healing  under  a  scab.  The  repair  of  subcutaneous 
wounds  may  be  effected  by  immediate  union,  but  is  generally  accom- 
plished by  connection,  or  the  formation  of  bonds  of  union  between  the 
divided  and  retracted  parts.  Very  rarely  it  is  effected  by  means  of 
granulations  without  suppuration. 

Of  these  modes,  which  I  hope  to  describe  hereafter  in  detail,  it  is 
the  peculiarity  of  the  first,  or  'process  of  immediate  union,  that  it  is 
accomplished  by  the  mere  reunion  or  rejoining  of  the  divided  parts, 
without  the  production  or  interposition  of  any  new  material.  In  all 
the  others,  new  material  is  produced  and  organized.  This  process  of 
immediate  union  corresponds  with  what  Mr.  Hunter  called  "union  by 
the  first  intention."  It  is  not  the  same  as  that  which,  in  modern  sur- 
gery, is  called  union  by  the  first  intention ;  for  that  is  the  same  as 
Mr.  Hunter  named  "union  by  adhesion,"  or  "by  the  adhesive  inflam- 
mation," and  is  effected,  as  he  described  it,  by  the  organization  of 
lymph  interposed  between  two  closely  approximated  wounded  surfaces. 
Mr.  Hunter  maintained  that  union  by  the  first  intention  is  effected  by 
means  of  the  fibrine  of  the  blood  extravasated  between  the  surfaces  of 
the  injured  part,  which  fibrine,  there  coagulating,  adheres  to  both  the 
surfaces,  becomes  organized,  and  forms  a  vascular  bond  of  union  be- 
tween them.*  Doubtless,  Mr.  Hunter  was,  in  this,  in  error ;  but,  as 
the  blood  extravasated  in  wounds  is  not  without  influence  on  their 
repair,  I  will  endeavor  to  state  the  several  modes  in  which  it  may,  when 
thus  extravasated,  be  finally  disposed  of. 

There  are  ample  evidences  for  believing  that  masses  of  effused,  or 
stagnant  and  coagulated,  blood  may  be  organized  ;  i.  e.  may  assume  the 
characters  of  a  tissue,  and  may  coalesce  with  the  adjacent  parts  and 
become  vascular.  These  evidences  include  cases  of  blood  effused  in 
serous  sacs,  especially  in  the  arachnoid  ;  of  clots  in  veins  organizing 
into  fibrous  cords,  or,  after  less  organization,  degenerating  into  phle- 
bolithes ;  clots  organizing  into  tumors  in  the  heart  and  arteries,  and 
the  clots  so  organized  above  ligatures  on  arteries  as  to  form  part  of 
the  fibrous  cord  by  which  the  obliterated  artery  is  replaced.  These 
last  cases  afford  most  conclusive  evidence,  because  they  have  been  very 
carefully  investigated  in  a  series  of  experiments  and  microscopic  obser- 
vations, by  Dr.  Zwicky.f 

In  1848,  I  had  the  opportunity  of  examining  a  specimen  which,  more 

*  Works,  vol.  iii,  253.  |  Die  Metamorphose  cles  Thrombus.  Zurich,  1845. 


REPARATIVE     MATERIALS. 


135 


fully  than  any  other  I  had  seen,  confirmed  Zwicky's  account  of  the 
mode  in  which  blood-clots  become  organized.  It  supplied,  too,  some 
facts  which  appear  important  to  the  present  subject.  It  was  obtained 
from  an  insane  person,  by  my  friend  Mr.  Holmes  Coote.  A  thin  layer' 
of  pale  blood-colored  and  ruddy  membrane  lined  the  whole  internal 
surface  of  the  cerebral  dura  mater,  and  adhered  closely  to  it.  Its 
color,  the  existence  of  patches  of  blood-clot  imbedded  in  it,  and  all  its 
other  characters,  satisfactorily  proved  that  it  had  been  a  thin  clot  of 
blood, — an  example  of  such  as  are  efi"used  in  apoplexy  of  the  cerebral 
membranes,  and  are  fully  described  by  Mr.  Prescott  Hewett.*  Nu- 
merous small  vessels  could  be  seen  passing  from  the  dura  mater  into 
this  clot-membrane  ;  and  with  the  microscope,  while  they  were  still  full 
of  blood,  I  made  the  sketch  engraved  (Fig.  13,  a).  The  arrangement  of 
the  bloodvessels  bears  a  close  resemblance,  but,  perhaps,  more  in  its 
irregularity  than  in  any  positive  characters  or  plan,  to  that  which 
exists  in  false  membrane  formed  of  organized  lymph  ;  but  the  vessels 
were,  I  think,  generally  larger. 

Such  were  the  bloodvessels  of  this  organized  clot.     Its  minute  struc- 
ture, as  represented  below  (b),  showed  characters  which  are  of  peculiar 


Fig.  13. 


interest,  because  of  their  resemblance  to  those  observed  in  the  material 
that  is  commonly  formed  in  the  repair  of  subcutaneous  injuries.  In 
the  substance  of  what  else  appeared  like  a  filamentous  clot  of  fibrine, 
sprinkled  over  with  minute  molecules,  the  addition  of  acetic  acid  brought 
into  view  corpuscles  like  nuclei,  or  cytoblasts,  very  elongated,  attenu- 
ated, and,  in  some  instances,  like  short  strips  of  flat  fibre.  Of  course,, 
such  corpuscles  are  not  to  be  found  in  any  ordinary  clot  of  fibrine  ;  they 


*  Med.  Chir.  Trans,  vol.  xxviii. 


136  REPARATIVE     MATERIALS. 

exactly  resemble  such  as  may  be  found  in  certain  examples  of  ruclimen- 
tal  connective  tissue,  and  among  these,  in  the  material  for  the  repair  of 
subcutaneous  injuries.  In  short,  the  minute  structure  of  this  clot  now 
'organized  was  an  example  of  what  I  shall  have  often  to  refer  to  under 
the  name  of  "  nucleated  blastema."* 

"With  such  evidence  as  this  of  the  organization  of  a  thin  layer  of 
blood-clot,  and  of  the  development  of  its  fibrine  being  apparently  iden- 
tical with  that  of  the  material  commonly  formed  for  the  repair  of  sub- 
cutaneous injuries,  I  was  surprised  to  find  that  extravasated  blood  can, 
commonly,  have  no  share  at  all  in  the  reparative  process. 

One  of  the  best  proofs  of  this  is,  that  scarcely  the  smallest  portion 
of  blood  is  effused  in  the  cases  in  which  the  largest  quantity  of  repara- 
tive material  is  produced  in  the  shortest  time,  and  in  which  the  healing 
process  is  most  perfectly  accoliiplished.  In  tAventy  cases  in  which  I 
divided  the  Achilles-tendon  in  rabbits,  I  only  once  found,  in  the  subse- 
quent examinations,  a  clot  of  extravasated  blood  in  the  track  of  the 
wound.  In  this  case,  I  believe,  the  posterior  tibial  artery  was  wounded : 
for  in  all  others,  and  in  similar  divisions  of  muscles,  unless  a  large  arte- 
rial trunk  were  cut,  the  only  effusion  of  blood  was  in  little  blotches,  not 
in  separate  clots,  but  infused  or  infiltrated  in  the  areolar  tissue  near  the 
wound.  In  some  cases  there  was  blood-stained  infiltration  of  the  in- 
flammatory products,  but  in  none  Avere  there  such  clots  as  could  be  or- 
ganized into  bonds  of  union.  In  short,  parts  thus  divided  scarcely 
bleed :  what  blood  does  flow  escapes  easily  through  the  outer  wound,  as 
the  surrounding  tissues  collapse  into  the  space  left  by  the  retracting 
parts ;  or,  what  remains  is  infiltrated  into  the  tissues,  and  forms  no 
separate  clot. 

It  is  the  same  with  fractures.  In  a  large  proportion  of  these,  one 
finds  no  clots  lying  between  the  fragments  where  they  are  to  be  united, 
and  only  very  small  spottings  of  blood,  like  ecchymoses,  in  or  beneath 
the  periosteum.  The  abundant  extravasations  that  commonly  exist  in 
the  subcutaneous  tissue  are  generally  confined  to  it :  they  are  not  con- 
tinued down  to  the  periosteum  or  bone. 

In  all  these  cases,  then,  we  have  sufficient  proof  that  extravasated 
blood  is  not  necessary  for  union  by  the  first  intention,  or  for  any  other 
mode  of  repair,  in  the  simple  fact  that  where  the  repair  is  best,  and  the 
material  for  it  most  ample,  no  blood  is  so  extravasated  as  to  form  a  clot 
that  could  be  organized. 

But,  though  this  may  be  the  usual  case,  the  question  still  remains — 
When  blood  is  efi"used  and  coagulated  between  wounded  surfaces,  how 

*  The  description  here  given  has  been  fully  confirmed  by  the  examination  of  a  similar 
membranous  clot,  the  vessels  of  which  were  beautifully  injected  by  Mr.  Gray  (Pathol. 
Trans.)  ;  a^id  more  recently  by  that  of  one  injected  by  Mr.  Coote.  Dr.  W.  T.  Gairdner,  in 
Edin.  Med.  Jour.  Oct.,  1851,  also  describes  a  specimen  of  false  membrane  from  the  arach- 
noid cavity,  in  which  bloodvessels  containing  blood-corpuscles  were  seen,  and  Dr.  J.  Ogle, 
in  Beale^s  Archives,  vol.  i,  and  part  6,  records  similar  cases. 


BLOOD.  137 

are  the  clots  disposed  of  'i  For,  often,  though  not  generally,  such  clots 
are  found  in  wounds,  or  between  the  ends  of  a  broken  bone,  or  a  di- 
vided tendon  when  an  artery  by  its  side  is  cut ;  and  in  most  operation- 
wounds,  one  sees  blood  left  on  them,  or  flowing  on  their  surfaces,  after 
they  are  done  up.     How,  then,  is  this  blood  disposed  of? 

If  effused  in  large  quantity,  so  as  to  form  a  voluminous  clot,  and 
especially  if  so  effused  in  a  wound  which  is  not  perfectly  excluded  from 
the  air,  or  if  effused  in  even  a  subcutaneous  injury  in  a  person  whose 
health  is  not  good,  the  blood  is  most  likely  to  excite  inflammation  ;  and 
the  swelling  of  the  wounded  parts,  or  their  commencing  suppuration, 
will  push  it  out  of  the  wound.     Thus  we  often  see  blood  ejected. 

But,  in  more  favorable  circumstances,  the  blood  may  be  absorbed ; 
and  this  may  happen  whether  it  have  formed  separate  clots,  or,  more 
readily,  when  it  is  infiltrated  in  the  tissues.  What  I  have  seen,  how- 
ever, in  the  experiments  to  which  I  have  already  referred,  leads  me  to 
dissent  from  the  account  commonly  given  of  the  absorption  of  blood 
thus  effused.  The  expressions  generally  used  imply  that  the  first  thing 
towards  the  repair  of  such  a  wound  is  the  absorption  of  the  extrava- 
sated  blood  ;  and  that  then,  in  its  place,  the  lymph  or  reparative  mate- 
rial is  produced.  But  this  can  hardly  be  the  case  ;  for  the  absorption 
of  blood  is  a  very  slow  process,  and  commonly  requires  as  much  time 
as  would  suffice  for  the  complete  healing  of  a  wound,  or  even  of  a  frac- 
ture. Not  to  mention  the  very  slow  absorption  of  the  extravasations 
of  blood  in  apoplexy  or  in  serous  sacs,  I  have  found  the  blood  effused 
in  the  subcutaneous  tissue  and  the  muscles,  after  a  simple  fracture, 
scarcely  changed  at  the  end  of  five  weeks  ;  that  in  a  tied  artery  was  as 
little  changed  after  seven  weeks :  and  even  in  common  leech-bites  we 
may  sometimes  find  the  blood-corpuscles,  in  little  ecchymoses,  un- 
changed a  month  after  their  extravasation  :  yet  in  much  less  time  than 
this  it  is  commonly  implied  that  all  the  blood  extravasated  in  an  injury 
is  cleared  quite  away,  that  lymph  may  occupy  its  place.  My  impres- 
sion is,  that  this  opinion  is  founded  on  imperfect  observations.  Blood 
is  supposed  to  be  effused  in  all  subcutaneous  injuries ;  and  where  it  is 
not  found,  it  is  supposed  to  have  been  absorbed ;  the  truth  rather  being, 
that,  where  no  blood  appears,  none  ever  was. 

The  true  method  of  the  absorption  of  blood  left  in  a  wound  seems  to 
be,  that  it  is  inclosed  within  the  reparative  material,  and  absorbed  by  the 
vessels  of  that  material  as  its  organization  proceeds.  The  best  instance 
that  I  have  seen  in  support  of  this  statement  was  in  the  case  of  a  rab- 
bit's Achilles-tendon,  divided  subcutaneously  six  days  before  death. 
The  reparative  process  had  proceeded  favorably,  and  as  strong  a  band 
of  union  as  is  usual  at  that  period  was  formed  of  the  new  reparative 
material  deposited  between  the  retracted  ends.  On  slitting  open  this 
band,  I  found  within  it  a  clot  of  blood,  such  as  must  have  come  from  a 
large  vessel ;  and  this  clot  was  completely  inclosed  within  the  new  ma- 
terial ;  not  closely  adherent  to  it,  nor  changed  as  if  towards  organiza- 

10 


138  EEPARATIVE    MATERIALS: 

tion  ;  but  rather,  decolorized,  mottled,  and  so  altered  as  clots  are  in 
apoplexy  before  absorption. 

I  believe  that  this  case  only  showed  in  a  very  marked  manner  what 
usually  happens  with  blood  thus  eifused  and  not  ejected :  for  it  is  quite 
common,  after  the  division  of  tendons,  to  find  new  reparative  material, 
if  not  containing  distinct  clots,  yet  blotched  with  the  blood  that  was 
infiltrated  in  the  tissue  in  which  the  reparative  material  is  deposited : 
and  even  when  the  repair  of  a  fracture  was  nearly  perfect,  I  have  still 
found  traces  of  blood-corpuscles  inclosed  in  the  reparative  material, 
and  degenerating,  as  if  in  preparation  for  absorption. 

Ejection  and  absorption  are,  doubtless,  the  usual  means  by  which 
blood  effused  in  injuries  is  disposed  of;  yet  I  feel  nearly  sure  it  may 
in  some  instances  become  organized,  and  form  part  of  the  reparative 
material.  The  cases  of  manifest  organization  of  blood  already  referred 
to  leave  no  doubt  of  the  possibility  of  this  happening :  its  occurrence 
can  no  longer  be  set  aside  as  a  thing  quite  improbable.  The  only 
question  is,  whether  blood  effused  in  injuries  has  been  seen  organized. 
Now  I  think  no  one  familiar  with  Hunter's  works  will  lightly  esteem 
any  statement  of  his  as  to  a  matter  of  observation.  He  may  have  been 
sometimes  deceived  in  thinking  that  he  saw  blood  becoming  organized 
in  subcutaneous  injuries  (for  subcutaneous  granulations  are  sometimes 
very  like  partially  decolorized  clots) ;  yet  I  believe  he  was  often  right : 
for  sometimes  one  finds  clots  of  blood  about  the  fractured  ends  of  bones 
which  have  every  appearance  of  being  in  process  of  organization. 
They  do  not  look  mottled,  or  rusty,  or  brownish,  as  extravasated  blood 
does  when  it  is  degenerating,  preparatory  to  its  absorption ;  but  they 
are  uniformly  decolorized  to  a  pinkish-yellow  hue.  They  have  more 
appearance  of  filamentous  structure  than  recent  clots  have  ;  and  they 
are  not  grumous  or  friable,,  like  old  and  degenerating  ones,  but  have  a 
peculiar  toughness,  compactness,  and  elasticity,  like  firm  gelatine. 
When  clots  are  found  in  this  condition,  I  believe  it  is  a  sign  that  they 
were  organizing;  for  this  is  the  condition  into  which,  commonly,  the 
clot  in  a  tied  artery  passes  in  its  way  to  be  fully  organized;  and 
(which  is  very  characteristic)  you  may  find  clots  in  the  track  of 
wounded  parts  thus  changing,  as  if  towards  organization,  while  those 
about  them,  and  out  of  the  way  of  the  reparative  process,  are  degene- 
rating. 

On  the  whole,  then,  I  believe  Ave  may  thus  generally  conclude  con- 
cerning the  part  that  blood,  when  it  is  extravasated,  takes  in  the  repair 
of  injuries : 

1.  It  is  neither  necessary  nor  advantageous  to  any  mode  of  healing. 

2.  A  large  clot,  at  all  exposed  to  the  air,  irritates  and  is  ejected. 

3.  In  more  favorable  conditions  the  eff"used  blood  becomes  inclosed 
in  the  accumulating  reparative  material;  and  while  this  is  organizing, 
the  blood  is  absorbed  ;  and, 

Lastly,  it  is  probable  that  the  blood  may  be  organized  and  form  part 


LYMPH.  139 

of  the  reparative  material ;  but  even  in  this   case  it  probably  retards 
the  healing  of  the  injury. 

I  proceed  now  to  the  consideration  of  the  new  material  which  is  pro- 
duced for  the  repair  of  injuries  that  are  not  healed  by  the  immediate 
union.  It  is  that  to  which  the  general  name  of  lymph,  or  coagulable 
lymph,  is  given. 

Our  notions  concerning  the  properties  of  this  substance,  when  once 
formed  for  the  repair  of  injuries,  are  derived  almost  entirely  from  ex- 
aminations of  the  lymph  formed  in  acute  inflammations,  with  which  it 
is  supposed  to  be  identical.  The  identity  is  far  from  being  proved,  but 
their  similarity  is  in  many  particulars  evident,  and  especially  in  that 
both  manifest,  by  their  spontaneous  coagulation,  that  they  contain 
fibrine.  The  coagulum  which  is  spontaneously  formed  in  reparative 
material  is,  in  microscopic  characters,  like  that  of  fibrine :  chemically, 
too,  they  appear  alike  :  and  the  organization  of  the  fibrine  of  the  blood 
in  the  complete  clot,  as  well  as  all  the  other  circumstances  which  lead 
to  the  opinion  that  fibrine  is  the  principal  material  for  organization  into 
tissues,  justifies  the  belief  that  the  lymph  exuded  for  the  purposes  of 
repair  has  fibrine  for  its  principal  constituent.  However,  when  we 
speak  of  fibrine  as  the  chief  reparative  material,  we  must  not  have  in 
mind  the  pure  organic  compound  that  minute  chemistry  might  obtain, 
but  rather  that  which  exists  in  the  natural,  and  seemingly  rough,  state, 
— as  fibrine,  with  some  fatty  matter,  and  some  incidental  saline  con- 
stituents ;  for  all  these  are  found  in  all  the  specimens  of  coagulable 
lymph  that  have  been  examined  ;  and  without  doubt  they  are  essential, 
as  the  so-called  "  incidental  principles"  always  are,  to  the  due  construc- 
tion of  the  substance  to  be  organized. 

Regarding  its  vital  properties,  the  essential  character  of  the  coagula- 
ble lymph  is  its  tendency  to  develop  itself;  a  tendency  which  it  has  of 
its  own  properties.  It  thus  displays  itself  as  a  plasma  or  blastema ;  a 
fluid  to  be  classed  with  those  others  that  manifest  the  capacity  to  assume 
organic  structure ;  such  as  the  lymph  and  chyle  that  develop  them- 
selves to  blood,  and  the  semen,  which,  at  first  fluid,  gradually  develops 
itself  into  more  and  more  complex  structures. 

The  natural  tendency  of  coagulable  lymph  is  to  develop  itself  into  the 
fibrous,  or  common  fibro-cellular  or  connective,  tissue — the  lowest  form 
of  vascular  tissue,  and  the  structure  which,  in  nearly  all  cases  in  man, 
constitutes  the  bond,  by  which  disunited  parts  are  again  joined.     This 
is  commonly  formed,  whatever  be  the  tissue  upon  which  the  lymph  is 
placed,  whether  containing  connective  tissue  in  its  natural  structure  or 
not.     This,  therefore,  we  may  regard  as  the  common  or  general  ten- 
dency of  lymph ;  but  in  certain  cases  the  development  of  lymph  passes- 
beyond  this  form,  or  deviates  from  it  into  another  direction,  in  adapta- 
tion to  the  special  necessity  of  the  part  to  be  repaired.     Thus,  for  the 
repair  of  bone,  the  lymph  may  proceed  a  certain  distance  towards  the 


140  EEPARATIVE    MATERIALS: 

development  of  fibrous  tissue,  as  if  for  a  common  healing ;  but  this 
fibrous  tissue  may  next  ossify  ;  or,  not  forming  fibrous  tissue  at  all,  the 
lymph  may  proceed  at  once  to  the  formation  of  a  nearly  perfect  carti- 
lage, and  this  may  ossify.  In  general,  moreover,  the  character  of  the 
connective  tissue  that  is  formed  in  repair  is  adapted  to  that  of  the  parts 
that  it  unites.  The  bond  for  the  union  of  a  tendon  is  much  tougher 
than  a  common  scar  in  the  skin ;  the  scar  in  skin  is  tougher  and  less 
pliant  than  that  in  mucous  membrane,  and  so  on. 

But,  passing  by,  for  the  present,  the  instances  of  special  development 
of  the  reparative  material,  in  adaptation  to  special  purposes  or  injuries, 
let  me  speak  of  its  development  into  fibrous,  fibro-cellular,  or  connec- 
tive tissue.  I  have  said  that,  in  its  first  production,  the  reparative  ma- 
terial is  like  the  lymph  of  inflamed  serous  membranes  ;  at  least,  no 
characteristic  difference  is  yet  known  between  these,  which  we  might 
call  respectively,  inflammatory  and  reparative  lymph.  Neither  are 
there  yet  any  observations  to  show  a  difference  in  the  primary  charac- 
ters of  the  materials  effused  for  the  repair  of  injuries  of  different  parts, 
or  in  different  circumstances ;  and  yet  such  a  difference,  in  even  the 
original  properties  of  the  reparative  lymph,  is  indicated  by  the  fact, 
that,  in  different  circumstances,  it  may  proceed  to  the  same  end — the 
formation  of  fibrous  tissue  —  by  two  different  ways  of  development. 
The  lymph,  or  new  material,  which  is  produced  for  the  repair  of  open 
wounds,  generally  develops  itself  into  connective  tissue  through  nu- 
cleated cells  ;  that  formed  for  the  healing  of  subcutaneous  wounds  as 
generally  develops  itself  into  the  same  tissue  through  the  medium  of 
nucleated  blastema. 

Now,  both  these  are  repetitions  of  natural  modes  of  development 'of 
the  same  forms  of  tissue.  And  it  must  not  appear  an  objection  that 
there  should  be  two  modes  of  development  to  the  same  perfect  structure  ; 
for  this  is  usual,  and  has  been  observed  in  nearly  all  the  tissues.  In  the 
development  of  the  blood-corpuscles,  a  first  set  are  formed  from  part  of 
the  embryo-cells  that  form  the  germinal  area,  or  the  whole  body  of  the 
embryo  ;  and  a  second  set  are  formed  from  the  corpuscles  of  lymph  and 
chyle.  So  it  is  with  the  cartilage,  the  muscular,  and  other  tissues  that 
are  formed  in  the  earliest  periods  of  embryo-life.  At  first  they  are  de- 
veloped from  some  of  the  embryo-cells;  yet  in  later  life  no  such  cells 
are  seen  among  them,  but  others  appropriate  to  them,  and  of  different 
form.  So  also  in  the  bones,  which  at  first  are  developed  through  carti- 
lage, but  in  their  subsequent  growth  are  increased  by  ossification  of 
fibrous  tissue  ;  and  in  the  repair  of  which  we  shall  find  even  more  numer- 
ous modifications  of  these  different  developments. 

The  development  of  the  fibro-cellular  or  connective  tissue  through 
nucleated  cells  may  be  observed  in  the  material  of  granulations,  or  in 
that  of  inflammatory  adhesions  (whether  in  a  serous  sac  or  in  a  wound 
healing  by  primary  adhesion),  in  inflammatory  indurations,  and  in  the 


LYMPH. 


141 


naturally  developed  connective  tissue  of  many  parts.  The  process  is, 
with  slight  and  apparently  not  essential  modifications,  the  same  in  all ; 
and  is,  I  believe,  almost  exactly  described  by  Schwann. 


Fig.  14.* 


The  cells  first  formed  in  granulations  are  spherical,  palely  or  darkly 
nebulous,  from  about  l-1800th  to  l-2500th  of  an  inch  in  diameter.  They 
contain  a  few  shining,  dark-bordered  granules,  and  lie  imbedded  in  a 
variable  quantity  of  clear  pellucid  substance,  by  which  they  are  held 
together,  and  which  it  is  hard  to  see,  unless  acetic  acid  be  added.  When 
water  is  added,  it  penetrates  the  cells,  and  as  they  swell  up  their  walls 
appear  more  distinct,  and  their  contents  are  diiFused.  Some  cells  thus 
become  much  larger  and  clearer,  and  show  in  their  interior  numer- 
ous vibrating  molecules :  others  display  fewer  molecules,  but  a  distinct 
round,  dark-bordered  nucleus,  which  appears  attached  to  the  inside  of 
the  cell-wall.  Such  a  nucleus  is  rarely  seen  in  granulation-cells,  unless 
they  are  distended  with  water :  acetic  acid,  acting  more  quickly  than 
water,  brings  the  nucleus  more  evidently  and  constantly  into  view,  and 
often  makes  it  appear  divided  into  two  or  three  portions. f 

In  the  development  of  fibro-cellular  or  connective  tissue  from  these 
cells,  whether  in  the  natural  structures  or  in  those  that  are  formed  in 
disease  or  after  injury,  the  first  apparent  change  is  in  the  nucleus. 
It  becomes  more  distinct ;  then  oval  (even  before  the  cell  does),  and  at 
the  same  time  clearer,  brighter,  like  a  vesicle  tensely  filled  with  pellucid 
substance.  One  or  two  nucleoli  now  appear  distinctly  in  it,  and  soon 
it  attenuates  itself;  but  this  it  does  later,  or  in  a  less  degree,  than  the 
cell ;  for  a  common  appearance  is  that  of  elongated  cells  bellied  out  at 
the  middle  by  the  nucleus. 


*  Development  of  graniilation-cells;  the  elongated  cells  in  the  group  below  are  sketched 
as  less  magnified  tlian  those  above. 

f  The  granulation-cells  are  very  like  the  white  or  lymph-corpuscles  of  the  blood:  but  the 
likeness  implies  nothing  more  than  the  general  fact  that  tnany  structures  which,  in  their 
perfect  state,  are  widely  diiferent  in  form  as  well  as  in  office,  have,  as  to  form,  the  same 
rudiinental  elements.  The  fact,  of  which  there  are  many  other  instances,  seems  the  more 
remarkable,  if  we  contrast  it  with  that  already  mentioned, — that  the  same  perfect  structure 
may  have  more  than  one  original  or  rudimental  form,  and  more  than  one  method  of  deve- 
lopment. 


142  REPARATIVE    MATERIALS: 

While  these  changes  are  ensuing  in  the  nucleus,  each  cell  also  is  de- 
veloping its  structure ;  first  becoming  minutely,  yet  more  distinctly, 
granular  and  dotted;  then  having  its  cell-wall  thinned,  or  even  losing 
it.  It  elongates  at  one  or  both  ends,  and  thus  are  produced  a  variety 
of  lanceolate,  caudate,  or  spindle-shaped  cells,  which  gradually  elongate 
and  attenuate  themselves  towards  the  filamentous  form.  As  they  thus 
change,  they  also  group  themselves ;  so  that,  commonly,  one  may  find 
the  swollen  part  of  each,  at  which  the  nucleus  lies,  engaged  between  the 
thinner  parts  of  the  two  or  more  adjacent  to  it.  Thus,  the  filaments 
into  which  the  cells  are  developed  are  clustered  or  fasciculated  :  each 
cell  forming,  I  think,  usually  only  one  filament,  and  long  filaments  being 
sometimes  formed  by  the  attachment  of  the  ends  of  two  or  more,  each 
developed  from  a  single  cell. 

In  some  granulations,  but,  I  think,  only  in  such  as  are  formed  on 
bones,  one  may  often  find  large  compound  cells,  or  masses,  or  laminae, 
of  blastema,  of  oval  form,  and  as  much  as  l-250th  of  an  inch  in  diame- 
ter, containing  eight,  ten,  or  more  nuclei.  They  are  like  certain  natu- 
ral constituents  of  the  medulla  of  bone  (as  described  by  Kolliker*  and 
Robinf);  and  like  the  bodies  which  are  found  constituting  the  chief  part 
of  fibro-plastic  tumors.  Sometimes,  also,  even  in  the  deeper  parts  of 
granulations,  cells  are  found  expanded,  flattened,  scale-like,  and  nu- 
cleated, as  if  approximating  to  the  formation  of  epidermal  cells. 

Such,  briefly,  is  the  process  for  the  development  of  fibro-cellular  tis- 
sue through  nucleated  cells  as  observed  in  granulations.  Some  modifi- 
cations of  it  may  be  noticed  in  certain  cases,  especially  in  regard  to  the 
proportion  that  the  cells  bear  to  the  substance  in  which  they  lie.  In 
some  forms  of  granulations,  as  in  some  natural  parts  of  the  embryo,  this 
substance  is  abundant :  and  I  presume  that  by  its  development  or  fibril- 
lation it  takes  part  in  the  formation  of  filaments.  But  none  of  the 
modifications  afi"ect  the  essential  characters  of  the  process. 

The  development  of  the  fibro-cellular  or  fibrous  tissue  through  nu- 
cleated blastema  is,  as  I  have  already  said,  best  observed,  among  the 
processes  of  repair,  in  the  organization  of  the  material  by  which,  in 
most  cases,  the  bonds  of  connection  after  subcutaneous  wounds  are 
formed.  It  is  the  same  process  whicli  Henle|  regards  as  the  only  mode 
of  development  of  the  fibro-cellular  and  fibrous  tissues. 

Of  the  union  of  divided  tendons  I  hope  to  speak  more  fully  in  a  future 
lecture.  For  the  present  purpose,  and  in  illustration  of  the  develop- 
ment of  fibro-cellular  or  fibrous  tissue  from  nucleated  blastema,  it  may 
be  enough  to  state  that,  when  the  first  exudation  of  the  products  of  the 
inflammation,  excited  by  the  violence  of  the  wound,  is  completed,  a 
quantity  of  flnely  molecular  or  dimly-shaded  substance,  like  homogene- 

*  Mikrosk.  Anatomie,  Figs.  113  and  121. 

t  Bull,  de  la  Societe  de  Biologie,  1  849,  p.  150. 

J  Allgemeine  Anatomie.    A  similar  process  is  described  by  Reichert,  Zwicky  and  Gerlach. 


LYMPH. 


143 


Fis.  15. 


ous  or  dotted  fibrine,  begins  to  appear  in  the  space  in  which  the  bond 
of  union  is  to  be  formed.  This  substance  is  infiltrated  in  the  tissue  that 
collapses  into  the  space  between  the  retracted  ends  of  the  tendon.  At 
first  there  is  no  appearance  of  nuclei  or  cytoblasts  in  it :  it  seems  to  be 
merely  a  blastema  of  fibrine :  but,  as  it  acquires 
firmness  and  distinctness,  the  nuclei  appear  in  it. 
They  presently  appear  as  oval  bodies,  with  dark 
hard  outlines,  soon  becoming  elongated;  they  have 
clear  contents,  without  nucleoli ;  they  are  irregu- 
larly scattered,  but  so  firmly  imbedded  in  the  blas- 
tema that,  in  general,  they  cannot  be  dislodged.  They 
may  be  seen  in  very  fine  fragments  without  re- 
agents ;  but,  commonly,  the  application  of  acetic 
acid  is  necessary  to  make  them  distinct,  by  making 
the  intermediate  substance  transparent,  while  the 
nuclei  themselves  appear  to  acquire  darker  edges 
and  shrivel  a  little.  The  nuclei  undergo  compara- 
tively little  change,  while  the  blastema  in  which  they  are  imbedded  is 
acquiring,  more  and  more  distinctly,  the  filamentous  appearance,  and 
then  the  filamentous  structure.  Only  they  appear  to  elongate,  and  to 
attenuate  themselves,  and  to  grow  more  irregular  in  their  outlines,  as  if 
by  shrivelling,  or  by  slight  branching. 

The  blastema  may  become  at  length  perfect  connective  tissue  ;  a  tis- 
sue not  to  be  distinguished  from  that  found  in  normal  conditions.  I 
have  not  been  able  to  find,  as  Henle  describes,  that  the  nuclei  are  de- 
veloped into  fibres. 


I  have  been  thus  minute  in  the  account  of  these  two  modes  of  develop- 
ment of  connective  tissue,  prevailing  alike  in  the  natural  structures  and 
in  the  materials  of  repair,  because  the  knowledge  of  them  may  enable 
us  to  settle  some  questions  respecting  all  the  modes  of  healing,  and  be- 
cause it  seems  to  point  out  the  essential  anatomical  difference  in  the 
healing  of  open  and  of  subcutaneous  wounds,  with  disconnection  of 
divided  parts. 

The  general  truth  appears  to  be  (as  already  stated)  that  the  material 
of  repair  for  subcutaneous  wounds  of  soft  parts  is  developed  through 
the  formation  of  nucleated  blastema  ;  whilst  that  for  repair  by  primary 
adhesion,  and  by  granulation,  is  developed  through  nucleated  cells. 
Now,  since  both  these  methods  of  development  are,  as  I  have  already 
said,  imitations  of  natural  methods,  we  might  suppose  that  they  are, 
therefore,  both  alike  natural  or  healthy  processes  ;  alike  sure  to  pass  to 
their  purposed  end,  safe  from  disease  or  degeneration.  But,  if  we  con- 
sider also  the  morbid  conditions  in  which  these  two  methods  of  develop- 
ment occur,  we  may  find  that  the  development  through  cells  is  charac- 
teristic of  a  less  perfect  process  of  healing  than  that  accomplished  with 
the  nucleated  blastema  that  appears  to  originate  in  a  fibrinous  exuda- 


144  REPARATIVE    MATERIALS:     LYMPH. 

tion.  For,  in  describing  the  products  of  inflammation,  I  shall  have  to 
show,  that  in  general,  the  inflammatory  exudations  which  occur  in  ple- 
thoric, sthenic  conditions  of  the  system,  or  in  local  disease  in  persons 
otherwise  sound,  have  the  aspect  of  fibrinous  substance,  like  the  mate- 
rials which  are  produced  in  subcutaneous  injuries,  and  are  developed 
through  nucleated  blastema  ;  while,  on  the  other  hand,  the  inflammatory 
exudations  in  debilitated  persons,  and  in  asthenic  blood-diseases,  assume 
a  corpuscular  structure,  like  that  of  granulations  upon  open  wounds. 

Let  me,. however,  in  conclusion,  state  that,  although  I  have  described 
the  two  modes  of  development  of  fibro-cellular  or  fibrous  tissue  for  the 
healing  of  wounds  as  if  they  were  always  as  separate  as  they  are 
distinct,  yet  they  may  coexist,  and  probably  often  do  so.  In  the 
repair  of  many  wounds,  the  two  materials,  namely,  that  which  is  to 
be  developed  through  nucleated  cells,  and  that  whose  progress  is  to  be 
through  nucleated  blastema,  may  be  mixed.  Thus,  in  subcutaneous 
wounds  and  injuries,  the  first  consequence  of  the  mechanical  violence 
is  the  exudation  of  a  common  inflammatory  product,  which  makes  the 
areolar  tissue  oedematous,  and  usually  organizes  itself  into  nucleated 
cells.  Thus  you  find  the  space  between  the  retracted  parts  of  divided 
tendons  for  about  two  days.  But  then,  the  more  proper  and  purer  ma- 
terial of  repair  is  produced ;  and  this,  increasing  in  an  inverse  propor- 
tion to  the  degree  of  inflammation,  soon  overwhelms  the  former  product 
of  inflammation,  and  is  developed  into  the  nucleated  blastema.  Still, 
for  many  days,  traces  of  the  inflammatory  product  may  be  discerned 
mingled  with  the  blastema,  confusing  its  appearance,  but,  I  believe, 
finally  organizing  with  it  into  the  bond  of  union.  So,  in  divided  mus- 
cles, and  in  simple  fractures,  the  inflammatory  exudation,  produced  in 
consequence  of  the  first  violence,  appears  to  mingle  and  develop  itself 
with  the  more  proper  material  of  repair  ;  but  they  bear  an  inverse  pro- 
portion to  one  another,  and  the  more  manifest  the  signs  of  the  inflam- 
mation, the  less  is  the  quantity  of  the  proper  reparative  material,  and 
the  slower,  in  the  end,  the  process  of  repair. 

On  the  other  hand,  I  think  that  in  the  ordinary  healing  of  open 
wounds,  which  are  soon  brought  together  by  sutures,  or  other  appro- 
priate means,  there  may  be  less  than  the  commonly  observed  formation 
of  nucleated  cells,  and  some  of  the  reparative  material  may  be  developed 
through  the  nucleated  blastema.  Or,  when  the  difi"erent  materials  are 
not  mingled  at  the  same  spot,  yet,  in  a  single  wound,  different  parts 
may  be  healed  by  the  organization  of  one  or  other  material,  according 
to  the  degree  of  inflammation  that  is  in  each  part  present.* 

*  The  structure  and  mode  of  development  of  the  fibro-ceUular,  fibrous,  or  connective  tis- 
sue, has,  during  the  last  ten  years,  more  especially  in  Germany,  formed  the  special  subject 
of  investigation  of  physiologists  and  pathologists,  and  many  observers  have  adopted  opi- 
nions on  these  questions,  which  differ  greatly  from  those  originally  announced  by  Schwann, 
and  incorporated  in  the  text.  As  the  whole  subject  must  still  be  considered  to  be  in  an  un- 
settled state,  it  has  been  thought  advisable  to  leave  the  text  very  much  as  it  was  in  the  for- 


HEALING    BY    IMMEDIATE     UNION.  145 

LECTURE    IX. 

THE    PROCESSES    OF    EEPAIR    OF    WOUNDS. 

1  PROCEED  now  to  the  description  of  the  several  modes  of  healing  of 
wounds,  and  shall  at  present  speak  of  only  such  wounds  as  are  exter- 
nally open.  Among  the  modes  which  I  enumerated,  the  first  was  that 
which,  as  I  stated  in  the  preceding  lecture,  is  effected  by  immediate 
union.     It  corresponds  with  what  Mr.  Hunter  called  union  by  the  first 

mer  edition,  and  to  throw  the  new  views  in  the  form  of  a  note.  It  is  to  Virchow  and  Bon- 
ders that  we  are  especially  indebted  for  the  observations  on  which  these  r\e-w  views  have 
been  founded.  At  first  much  opposition  was  advanced  to  their  statements.  Kolliker,  even 
in  the  last  edition  of  his  "  Manual  of  Microscopic  Anatomy,"  still  held  by  the  old  description  of 
Schwann,  but  in  a  recent  elaborate  paper  (Neue  Untersuchungen  iiber  die  Entwicklung  des 
Bindegewebes;  Wiirzburg,  ]861),  he  has,  to  a  great  extent,  announced  his  adhesion  to  the 
doctrines  of  Virchow  and  Donders.  These  observers  argue  that  the  fibrillated  bundles  are 
not  formed  from  cells,  but  that  they  arise  in  the  substance  lying  between  and  separating 
the  cells  from  each  other,  that  they  are  therefore  peculiar  modifications  of  intercellular  sub- 
stance. They  consider  that  the  cells  themselves  remain  in  the  texture  and  constitute  the 
connective-tissue  corpuscles.  Although  capable  of  undergoing  considerable  modifications, 
both  of  shape  and  chemical  composition,  yet  they  frequently  become  elongated  and  send 
out  processes,  partly  from  their  ends  and  partly  from  their  sides,  which  extend  between 
adjacent  bundles  of  fibrillse,  so  that  the  processes  proceeding  from  one  cell  become  con- 
nected to  those  belonging  to  adjacent  cells.  In  this  manner  a  stellated,  or  radiated  anasto- 
mosing system  of  cells  is  formed,  between  which  the  bundles  of  fibrillae  are  situated.  This 
system  of  cells  in  its  relation  to  the  mode  of  nutrition  of  the  connective  tissue,  has  been 
already  referred  to  on  p.  48.  Anatomists  had  long  been  familiar  with  the  fact  that,  when 
acetic  acid  wa?  added  to  the  fibrous  connective  tissue,  numerous  small  corpuscles,  gene- 
rally termed  the  nuclei  of  the  texture,  previously  hidden  by  the  fibrillated  bundles,  came  into 
view,  whilst  at  the  same  time  the  fibrillse  disappeared.  Bat  the  connection  of  these  corpus- 
cles with  each  other,  through  anastomosing  processes,  was  not  at  that  time  recognized.  In 
some  of  the  more  delicate  varieties  of  connective  tissue,  met  with  in  the  young  of  the  higher 
vertebrata,  and  in  the  more  strongly  developed  forms  in  some  of  the  lower  vertebrata,  as  in 
the  skin  of  certain  fish,  both  cells  and  fibres  may  be  seen  to  coexist,  without  the  addition  of 
any  reagent,  though  it  does  not  necessarily  follow  that  the  cells  in  these  cases  possess  a  ra- 
diated and  anastomosing  arrangement.  In  the  denser  and  more  compact  forms — tendons, 
ligaments,  fascise — the  bundles  of  fibres  are  so  closely  arranged,  that  the  cellular  element  is  at 
first  sight  entirely  concealed  by  them.  It  is  only  after  boiling,  or  the  application  of  strong 
acids,  that  the  cell  network  can  be  detected.  Forster  (Virchow's  Archiv,  1859,  18th  vol.) 
has  succeeded  by  digesting  sections  of  dried  tendons  and  other  connective  structures  in  con- 
centrated nitric  acid,  and  then  placing  glycerine  around  the  sections,  not  only  in  demonstrat- 
ing the  existence  of  the  radiated  arrangement  of  the  cells,  but  even  in  isolating  them.  Dr. 
Beale,  from  his  inquiries  into  the  structure  of  the  tissues,  has,  in  the  Gulstonian  Lectures  for 
1861,  arrived  at  opinions  diflfering  from  those  of  Virchow.  He  regards  the  system  of  anas- 
tomosing cells,  not  as  a  tubular  system,  but  filled  with  a  soft  substance,  "germinal  matter," 
on  which  the  growth  and  maintenance  of  the  whole  texture  depends. 

There  is  still  considerable  difficulty  in  deciding  whether  the  yellow  elastic  fibre  is  a 
cellular  or  intercellular  development.  Donders  (Zeitsch.  f.  Wissen,  Zool.  iii),  and  Virchow 
(Cellular  Pathologie)  hold  that  it  is  derived  from  peculiar  chemical  changes  in  and  con- 
densation of  the  walls  of  the  connective-tissue  cells  themselves.  H.  Miiller  (Bau  der  Mo- 
len,  S.  62),  Henle  (Canstatt,  1851),  and  more  recently  Kolliker  (Op.  cit.),  on  the  other  hand, 
regard  it  as  produced  by  peculiar  changes  in  the  fibrillar  gelatine-yielding  substance  be- 
tween the  cells,  so  that,  like  the  fibrous  bundles,  it  is  an  intercellular,  and  not  a  cellular, 
structure. 


146  HEALING    BY    IMMEDIATE    UNION. 

intention ;  but,  since  that  term  has  been  applied  more  recently  to 
another  mode  of  healing,  I  have  adopted  the  term  "immediate  union" 
from  Dr.  Macartney,  who,  so  far  as  I  know,  was  the  first  to  observe 
clearly  that  the  healing  of  wounds  may  be  eifected  "  without  any  inter- 
vening substance,  such  as  blood  or  lymph."*  He  says  :  "  The  circum- 
stances under  which  immediate  union  is  efiected,  are  the  cases  of  incised 
wounds  that  admit  of  being,  with  safety  and  propriety,  closely  and  im- 
mediately bound  up.  The  blood,  if  any  be  shed  on  the  surface  of  the 
wound,  is  thus  pressed  out,  and  the  divided  bloodvessels  and  nerves  are 
brought  into  perfect  contact,  and  union  may  take  place  in  a  few  hours ; 
and  as  no  intermediate  substance  exists  in  a  wound  so  healed,  no  mark 
or  cicatrix  is  left  behind. 

"  We  have  familiar  examples  of  this  mode  of  healing  in  slight  cuts 
received  on  the  fingers,  which,  after  being  bound  up,  if  no  inflammation 
be  induced,  perfectly  heal  without  the  individual  having  any  unpleasant 
sensation  in  the  part  after  the  moment  of  the  infliction  of  the  wound. 
A  case  has  been  lately  communicated  to  me,  of  a  considerable  cut  of 
the  hand  having  been  cured  by  this  mode  of  direct  union,  without  any 
sensation  of  pain,  in  the  short  space  of  four  or  five  hours." 

It  is  singular  that  Dr.  Macartney  should  speak  of  the  process  of  im- 
mediate union  occurring  in  so  few  and  very  trivial  instances  as  these ; 
for  it  seems  certain  that  many  even  very  large  wounds  are  usually,  in 
favorable  circumstances,  thus  healed.  The  characteristics  of  this  mode 
are,  that  the  divided  parts,  being  placed  in  exact  contact,  simply  con- 
join or  reunite ;  no  blood  or  new  material  is  placed  between  them  for  a 
connecting  bond,  and  no  sign  or  product  of  inflammation  is  present. 
All  these  characters  meet  in  such  cases  as  the  favorable  union  of  flaps 
of  skin,  which  have  been  reflected  from  the  subjacent  parts,  and  are 
then  replaced  or  transferred  to  some  other  adjacent  wounded  surface. 

The  instances  in  which  I  have  best  observed  it  have  been  after 
wounds  reflecting  portions  of  the  scalp,  and  after  operations  for  the 
removal  of  the  mammary  gland.  In  these  operations,  as  you  know,  the 
usual  proceeding  is  to  remove  some  of  the  skin,  including  the  nipple, 
and  to  uncover  the  rest  of  the  surface  of  the  gland  by  reflecting  from  it 
an  upper  and  lower  flap  of  skin.  Then  the  gland  being  removed,  these 
flaps,  which  are  often  of  considerable  extent,  are  laid  doAvn  upon  the 
parts  on  which  the  base  of  the  gland  rested,  chiefly  upon  the  fascia  over 
the  great  pectoral  muscle. 

One  of  the  first  specimens  I  examined  well  illustrated  the  healing 
that  may  now  ensue.  It  was  taken  from  a  woman  thirty-three  years 
old,  whose  breast  and  several  axillary  glands  were  removed  for  cancer. 
Her  general  health  seemed  good,  and  all  went  on  well  after  the  opera- 
tion. The  flaps,  which  were  of  course  very  large,  had  been  carefully 
laid  down,  strapped  with  isinglass  plaster,  and  well  tended.     They  ap- 

*  Treatise  on  Inflammation,  p.  49. 


HEALING    BY    IMMEDIATE    UNION.  147 

peared  to  unite  in  the  ordinary  way,  and  tliere  remained  only  a  narrow 
space  between  their  retracted  edges,  in  which  space  granulations  arose 
from  the  pectoral  muscle.  Three  weeks  after  the  operation  these  were 
making  good  progress  towards  cicatrization ;  but  erysipelas  and  phle- 
bitis ensued,  and  the  patient  died  in  four  or  five  days. 

I  cut  off  the  edges  of  the  wound  with  the  subjacent  parts,  expecting 
to  find  the  evidences  of  union  by  organized  lymph,  or,  possibly,  blood. 
But  neither  existed ;  and  the  state  of  parts  cannot  be  better  described 
than  by  saying  that  scarcely  the  least  indication  remained  of  either  the 
place  where  the  flap  of  skin  was  laid  on  the  fascia,  or  the  means  by 
which  they  were  united.  It  was  not  possible  to  distinguish  the  relation 
which  these  parts  held  to  each  other  from  that  which  naturally  exists 
between  subcutaneous  fat  and  the  fascia  beneath  it.  There  Avas  no 
unnatural  adhesion ;  but,  as  the  specimen,  which  is  in  the  Museum  of 
St.  Bartholomew's,  will  still  show,  the  subcutaneous  fat  which  did  lie 
over  the  mammary  gland  was  now  connected  with  the  fascia  over  the 
pectoral  muscle,  just  as  (for  example)  the  corresponding  fat  below  the 
clavicle  is  naturally  connected  to  the  portion  of  the  same  fascia  that 
lies  there.  The  parts  were  altered  in  their  relations,  but  not  in  their 
structure.  I  could  find  small  points  of  induration  where,  I  suspect, 
ligatures  had  been  tied,  or  where,  possibly,  some  slight  inflammation 
had  been  otherwise  excited ;  and  one  small  abscess  existed  under  the 
lower  flap.  But  with  most  careful  microscopic  examination,  I  could 
discover  no  lymph  or  exudation-corpuscles,  and  only  small  quantities  of 
what  looked  like  the  debris  of  such  oil-particles  or  corpuscles  of  blood 
as  might  have  been  between  the  cut  surfaces  when  the  flaps  were  laid 
down.  In  short,  we  cannot  otherwise  more  minutely  describe  this 
healing  than  by  the  term  "  immediate  union  :"  it  is  immediate  at  once 
in  respect  of  the  absence  of  any  intermediate  substance  placed  between 
the  wounded  surfaces,  and  in  respect  of  the  speed  with  which  it  is  ac- 
complished. 

Opportunities  of  examining  wounds  thus  healed  being  rare,  I  made 
three  experiments  on  rabbits  (with  my  friend  Mr.  Savory),  and  found 
the  description  I  have  just  given  quite  confirmed.  A  portion  of  skin, 
which  my  extended  fingers  would  just  cover,  was  raised  from  the  back 
of  a  rabbit,  replaced  and  fastened  down  with  a  few  sutures.  Three 
days  afterwards  the  rabbit  was  killed.  The  edges  of  the  wound  Avere 
slightly  retracted,  and  the  space  between  them  was  covered  with  scab 
for  about  half  an  inch  under  the  edge  of  the  replaced  flap  of  skin,  the 
tissue  was  inflamed  and  infiltrated  with  exudation-matter ;  but  beyond 
this  no  trace  of  the  injury  or  of  its  healing  could  be  seen.  The  parts 
appeared  as  they  had  appeared  before  the  operation.  Even  the  micro- 
scope could  detect  only  a  slight  infiltration  of  inflammatory  matter, 
which  one  might  certainly  ascribe  to  the  wound  being  open  at  its  edges, 
and  to  some  hairs  having  by  accident  been  inclosed  under  the  flap  when 
it  was  replaced. 


148  HEALING    BY    IMMEDIATE     UNION. 

Of  course,  it  is  only  from  such  examinations  as  these  after  death, 
that  we  can  speak  certainly  of  the  absence  of  inflammation  and  of  all 
intermediate  uniting  substances ;  yet  confirmatory  evidence  may  be 
obtained  from  the  examination  of  any  such  wound  during  life, — I  mean 
in  any  such  case  as  that  of  a  flap  of  skin  raised  up,  then  laid  down  on 
the  subjacent  wounded  surface,  and  there  uniting  favorably ;  or  in  any 
case  of  that  kind  of  plastic  operation  in  which  a  flap  is  raised,  and  then 
made  to  slide  to  some  further  position.  In  such  cases,  with  favorable 
progress,  no  sign  of  inflammation  is  observed  ;  though,  if  the  skin  were 
in  even  a  small  degree  inflamed,  it  could  scarcely  fail  to  be  manifested 
by  the  ordinary  appearances  of  redness  and  heat.  If  the  flap  be  pressed, 
no  fluid  oozes  beneath  its  edges  (I  speak,  of  course,  of  only  such  cases 
as  are  making  favorable  progress) ;  and  after  one  or  two  days,  accord- 
ing to  the  extent  of  the  wound,  the  flap  will  move  on  the  subjacent 
parts,  not  with  the  looseness  of  a  part  separate  from  them,  nor  with  the 
stiffness  of  one  adherent  through  inflammation,  but  with  the  easy  and 
pliant  sliding  which  is  peculiar  to  the  natural  connection  of  the  skin 
with  the  subjacent  fascia. 

Such  is  the  nature  of  "immediate  union  ;"  the  best  imaginable  pro- 
cess of  healing.  Two  conditions  appear  essential  to  it :  flrst,  exactness 
of  the  coaptation  of  the  wounded  surfaces ;  and  secondly,  the  absence 
of  all  inflammatory  process. 

To  obtain  the  former,  the  simple  replacement  of  the  raised  pieces  of 
skin  may  sometimes  be  sufiicient.  But  there  is  a  class  of  cases  to  which 
this  mode  of  healing  is  peculiarly  applicable,  and  in  which  more  than 
this  may  be  required ;  I  refer  to  the  removal  of  the  large  subcutaneous 
tumors, — fatty  tumors  and  the  like, — where,  after  the  operation,  large 
cavities  are  left,  and  commonly  left  to  granulate.  In  these  cases  I 
believe  that  modern  surgery  does  not  often  enough  employ  the  older 
method  of  carefully  and  softly  padding  the  parts,  and  of  so  bandaging 
them  that  the  exposed  surfaces  may  be  held  in  contact  for  the  one,  two, 
Or  three  days  necessary  for  immediate  union.  Many  surgeons,  I  know, 
commonly  employ  these  means,  but  by  many  they  are  avoided,  through 
fear  of  exciting  inflammation  by  overheating  the  parts,  or  hindering 
the  discharge  of  secreted  fluids.  Doubtless,  no  single  rule  of  manage- 
ment would  be  safe ;  but  I  think,  with  regard  to  this  fear  of  exciting 
inflammation,  it  need  not  be  entertained,  if  the  means  I  have  alluded 
to  be  employed  only  during  the  first  two  or  three  days  after  the  inflic- 
tion of  the  wound.  For  one  may  generally  observe  that  for  at  least 
two  or  three  days  after  such  an  injury  as  an  amputation,  the  raising  of 
a  flap  of  skin  in  a  removal  of  the  breast,  or  the  like,  scarcely  any  repara- 
tive process  appears  in  the  parts  that  are  kept  from  contact ;  no  granula- 
tions are  formed,  no  pus  secreted,  only  a  little  serous-looking  fluid  oozes 
from  them.  Now,  during  this  calm,  which  would  certainly  not  be  dis- 
turbed by  the  parts  being  softly  padded  and  kept  in  perfect  rest,  the 
immediate  union  may  be  accomplished.     If  through  any  untoward  cir- 


HEALING    BY     PRIMARY    ADHESION.  149 

cumstance,  it  be  not  in  this  period  completed,  its  occurrence  is,  I  believe, 
impossible,  and  then  the  means  more  appropriate  for  other  methods  of 
healing  may  be  employed. 

The  attainment  of  the  other  necessary  condition,  the  absence  of  in- 
flammation, is  quite  consistent  with  these  means  for  insuring  perfect 
and  continued  contact  of  the  wounded  surfaces.  How  the  condition  is 
to  be  fulfilled  I  need  not  say ;  the  means  are  some  of  those  that  are 
commonly  laid  down  for  preventing  inflammation  from  being  as,  it  is 
said,  more  than  is  necessary  for  the  union  by  the  first  intention ;  and 
the  best  of  them  are  temperance,  rest,  and  uniform  temperature.  The 
necessity  of  observing  them  will  appear  the  greater,  if  it  is  remembered 
that  what  is  wanted  for  immediate  union  is,  not  a  certain  undefined 
slight  degree  of  inflammation,  but  the  complete  absence  of  inflammation ; 
for  the  probability  of  the  occurrence  of  immediate  union  may  be  reckoned 
as  being  in  an  inverse  ratio  to  the  probability  of  inflammation  occurring 
in  the  time  necessary  for  its  accomplishment. 

The  second  mode  of  repair  that  I  enumerated  is  that  by  lirimary  ad- 
hesion. 

This  is  the  process  which  Mr.  Hunter  named  union  by  adhesion,  or 
union  by  the  adhesive  inflammation.  My  reasons  for  preferring  the 
term  "primary  adhesion"  will  presently  appear.  He  says,  "Where 
the  former  bond  of  union  \i.  e.,  the  union  by  blood  or  by  the  first  in- 
tention] is  lost  in  a  part,  to  produce  a  new  one  a  second  operation  takes 
place,  namely,  inflammation."*  Observe  how  carefully  Mr.  Hunter 
distinguishes  the  case  in  which  inflammation  ensues,  from  that  in  which 
none  is  necessary  :  and  presently  after, — "If  the  divided  parts  are  al- 
lowed to  remain  till  the  mouths  of  the  divided  vessels  are  entirely  shut, 
inflammation  will  inevitably  follow,  and  will  furnish  the  same  materials 
for  union  which  are  contained  in  extravasated  blood,  by  throwing  out 
the  coagulated  lymph  ;  so  that  union  may  still  take  place,  though  some 
time  later  after  the  division  of  the  parts.  This  inflammation  I  have 
called  the  adhesive."  On  this  sentence,  Mr.  Palmer,  expressing  the 
opinion  entertained  by  all  the  pathologists  of  some  tAventy  years  ago, 
says  :  "  It  is  now  generally  considered  that  union  by  the  first  intention 
and  adhesive  inflammation  are  essentially  the  same  processes,  modified 
by  the  degree  of  inflammation.  Union  by  the  first  intention  is  uniformly 
attended  with  some  degree  of  pain  and  swelling,  together  with  increased 
heat  and  vascularity,  which,  taken  conjointly,  constitute  the  definition 
of  inflammation."  And  again:  "According  to  the  modern  views,  the 
modes  of  union  above  detailed  \i.  e.,  the  modes  of  union  included  by  Mr. 
Hunter  under  the  union  by  the  first  intention]  are  always  accompanied 
by  adhesive  inflammation The  parts  are  united,  not  by  the  ex- 
travasated blood  becoming  vascular,  but  by  the  efi"usion  and  organiza- 
tion of  coagulable  lymph." 

*  Works,  vol.  iii,  p.  253. 


150  HEALING    BY    PRIMAEY    ADHESION. 

After  what  I  have  said  respecting  the  process  of  immediate  union,  it 
may  appear  that  Mr.  Hunter  was  more  nearly  right  than  his  successors. 
It  would  be  an  instructive  piece  of  the  history  of  surgery,  to  show, 
exactly,  how  his  truth,  being  mixed  with  error,  came,  therefore,  to  be 
thrown  away,  and  to  make  room  for  an  error  which  had  less  truth 
mixed  with  it.  The  stages  of  transition  in  opinions  seem  to  have  been, 
that,  first,  sufficient  reason  was  found  for  disbelieving  Hunter's  state- 
ment, that  blood  forms  the  bond  of  union  by  the  first  intention ;  then, 
as  it  was  assumed  that  there  must  always  be  some  intermediate  bond, 
this,  it  seemed,  could  be  none  but  coagulable  lymph.  Now,  coagulable 
lymph  being  known  only  as  the  product  of  inflammation,  it  followed 
that  inflammation  must  be  necessary  for  the  healing  of  every  wound ; 
and  then  there  ceased  to  be  any  distinction  between  the  union  by  the 
first  intention  and  the  union  by  adhesion  ;  both  alike  seemed  to  be  the 
result  of  lymph,  the  product  of  inflammation,  being  exuded  between  the 
wounded  surfaces,  and  united  to  them  both. 

Typical  examples  of  union  by  primary  adhesion  may  be  watched  in 
the  cut  edges  of  skin  that  are  brought  near  together.  When  the  cut 
surfaces  are  not  in  exact  contact,  the  wound  is  exposed,  and  lymph  is 
formed,  and  fills  up  the  space ;  or,  when  they  are  in  contact,  the 
sutures,  or  other  means  employed  to  keep  them  so,  excite  inflammation 
enough  for  the  production  of  some  lymph  between  them.  The  lymph 
is  simply  laid  on  the  cut  surfaces  ;  and  scarcely  any  is  infiltrated  in  the 
tissues.  Organizing  itself,  and  becoming  vascular,  it  connects  the  two 
edges  or  surfaces,  and,  finally,  forms  between  them  a  thin  layer  of  con- 
nective tissue,  on  the  surface  of  which,  if  it  be  exposed,  a  very  delicate 
layer  of  cuticle  is  developed.  The  smooth  shining  surface  of  this  cuticle 
gives  the  peculiar  character  of  the  scar,  and  one  that  scarcely  changes, 
except  in  the  alteration  of  apparent  color,  when  the  new  material 
becomes  less  vascular. 

The  lymph  efl"used  in  the  healing  by  primary  adhesion  always,  so  far 
as  I  know,  develops  itself  with  formation  of  nucleated  cells,  and,  doubt- 
less, the  whole  process  is  very  similar  to  that  of  the  adhesion  of  inflamed 
serous  membranes. 

Xt  may  be  very  quickly  accomplished.  A  boy  died  eighty  hours 
after  receiving  a  lacerated  wound  of  the  abdomen  ;  and,  for  forty-eight 
hours  of  these  eighty,  he  was  so  manifestly  dying,  that  I  think  no 
reparative  process  could  have  been  going  on.  A  portion  of  the  edges 
of  the  wound  was  united  with  lymph,  which  presented  well-marked 
cells,  like  those  of  granulations,  and  contained  looped  bloodvessels  full 
of  blood. 

But  it  may  be  accomplished  more  quickly  than  in  this  case.  In  a 
rabbit  that  I  operated  on  as  for  a  hare-lip,  I  found,  after  forty-eight 
hours,  the  edges  of  the  wounds  partially,  but  firmly,  united  by  lymph, 
many  of  the  cells  of  which  were  already  elongated,  in  such  development 
as  I  have  already  described.     Or,  even  more  quickly  than  in  this  in- 


HEALING    BY    GRANULATION.  l&l 

stance :  if  a  small  abscess  be  opened,  and  the  edges  of  the  opening  are 
not  gaping  or  inverted,  they  may  be  found  united,  except  at  the  middle, 
within  twenty-four  hours.  I  have  seen  them  so  united,  with  a  distinct 
layer  of  soft,  pinkish,  new  substance,  in  a  wound  made  seventeen  hours 
previously. 

There  are  no  cases  in  which  the  process  of  primary  adhesion  can  be 
better  observed  than  after  operations  for  hare-lip.  The  inner  portions 
of  the  wounds  made  in  them  may  be  healed  by  the  immediate  union, 
when  the  surfaces  have  been  in  exact  coaptation ;  but  the  edges  of  the 
skin  and  mucous  membrane  seem  always  united  by  the  adhesive  inflam- 
mation, for  a  scar  is  always  visible — a  scar  formed  by  the  lymph  or- 
ganized into  connective  tissue  and  epithelium,  and  one  which,  as  well  as 
any,  shows  how  little  of  assimilative  force  can  be  exercised  by  adjacent 
tissues ;  for  narrow  as  it  may  be,  it  does  not  become  quite  like  the 
adjacent  skin,  nor,  like  it,  bear  perfect  epidermis  and  hair. 

The  history  of  union  by  primary  adhesion  cannot  be  conveniently 
completed  till  an  account  has  been  given  of  the  healing  by  granulation 
and  by  secondary  adhesion.  Of  these  I  will  next  speak  ;  now  I  will 
only  say  of  this  union  by  primary  adhesion,  that  it  is  less  desirable 
than  the  immediate  union,  because  1st,  it  is,  probably,  not  generally  so 
speedy ;  2dly,  it  is  not  so  close,  and  a  scar  is  always  formed  by  the 
organization  of  the  new  matter ;  and  3dly,  the  formation  of  lymph-  or 
exudation-cells  is  a  process  so  indefinitely  separated  from  that  of  the 
formation  of  pus-cells,  that  union  by  primary  adhesion  is  much  more 
likely  to  pass  into  suppuration  than  any  process  is  in  which  no  lymph 
is  formed. 

In  describing  the  modes  of  healing  by  granulation  and  by  secondary 
adhesion,  I  shall  venture  again  to  take  my  account  from  certain  typical 
examples  :  such  as  cases  in  which,  after  amputation  of  a  limb,  the  sur- 
faces of  the  wound  are  not  united  by  either  of  the  means  already  de- 
scribed, but,  as  the  expression  is,  are  left  to  "granulate;"  or  such 
cases  as  the  removal  of  a  breast,  and  subsequent  suppuration  of  the  flaps 
and  the  exposed  fascia ;  or  such  as  wounds  into  inflamed  parts,  when 
the  edges  gape  wide  asunder,  and  the  spaces  left  between  them  are 
filled  up  with  granulations.  These  may  serve  as  examples  of  a  process 
which,  although  in  all  cases  it  may  preserve  certain  general  features  of 
similarity,  is  yet  in  detail  almost  infinitely  diversified,  and  often  so 
inexplicably,  that  any  more  than  a  general  account  of  it  might  fill 
volumes. 

Granulations  will  generally  arise  on  all  wounded  surfaces  that  are 
left  open  to  the  air  and  are  not  allowed  to  dry.  They  will  do  so  whether 
this  exposure  be  continued  from  the  first  infliction  of  the  wound,  or 
commence  after  the  edges,  which  have  been  brought  together,  have 
been  again  forced  asunder  by  the  swelling  of  the  deeper-seated  parts, 
or  by  hemorrhage,  or  secretion  of  fluid,  between  them.     Exposure  of 


152  HEALING    BY    GRANULATION. 

a  wound  to  the  air  is  not  prevented  by  any  ordinary  dressings  :  the  air 
that  is  inclosed  beneath  them,  or  that  can  penetrate  them,  appears  to 
be  quite  enough  to  determine  all  the  difference  of  the  events  that  fol- 
low open  and  subcutaneous  injuries. 

The  simplest  case  for  illustration  is  that  of  an  open  gaping  incised 
wound,  which,  from  the  time  of  its  infliction,  is  only  covered,  as  in  ordi- 
nary practice,  with  water-dressing,  or  some  soft  and  moist  substance. 
Blood  gradually  ceasing  to  flow  from  the  surface  of  such  a  wound,  one 
may  see  still  some  blood-tinged  serous-looking  fluid  oozing  from  it. 
Slowly,  as  this  becomes  paler,  some  of  it  collects,  like  a  whitish  film 
or  glazing,  on  the  surface  ;  and  this,  if  it  be  examined  with  the  micro- 
scope, will  be  found  to  contain  an  abundance  of  corpuscles,  having  the 
appearance  of  white  corpuscles  of  the  blood,  imbedded  in  a  fibrinous  film. 
The  collection  of  these  corpuscles  on  the  surface  of  the  wound,  espe- 
cially on  wounded  muscles  and  fasciae,  appears  to  depend  only  on  the 
peculiar  adhesiveness  which  they  exhibit  as  soon  as  they  are  removed 
from  the  canal  of  the  healthy  bloodvessel,  and  brought  in  contact  with 
extraneous  substances.  One  sees  them  adhering  much  more  firmly 
than  ever  the  red  corpuscles  do  to  the  glass  on  which  they  are  examined ; 
and  so  on  cut  surfaces,  while  the  other  constituents  of  the  blood  flow 
away,  the  white  corpuscles,  and,  probably,  also  some  of  the  fibrine 
quickly  coagulating,  adhere.* 

I  am  not  aware  of  any  facts  that  would  prove  what  share  the  white 
corpuscles  thus  collected  may  take  in  the  healing  of  a  wound.  They 
do  not  hinder  it ;  for  it  is  by  many  believed  to  be  favorable  to  union  by 
primary  adhesion,  to  leave  cut  surfaces  exposed,  till  they  appear  glazed 
over  with  the  whitish  film,  and  then  to  put  them  into  contact.  It  is 
probable  the  corpuscles  are  organized  when  the  surfaces  that  they  cover 
are  brought  together ;  but  I  know  of  no  facts  bearing  on  the  point,  and 
it  is  one  which  I  think  experiments  on  animals  could  hardly  be  made  to 
illustrate. 

If  a  wound  be  left  open,  the  glazing  remains  on  such  parts  as  it  may 
have  formed  on,  especially  on  the  exposed  muscles.  No  evident  change 
ensues  in  it,  except  that  it  appears  to  increase  slowly,  and  makes  the 
surface  of  the  wound  look  as  if  covered  with  a  thin  grayish  or  yellow- 
ish-white layer  of  buffy  coat.  This  increase  of  glazing  is  the  prelude 
of  the  formation  of  granulations  ;  but  while  it  is  going  on,  and  often, 
for  some  days  later,  there  is,  in  and  about  the  wound,  an  appearance  of 
complete  inaction  ;  a  calm,  in  which  scarcely  anything  appears  except  a 
slight  oozing  of  serous  fluid  from  the  wound.  Such  a  calm  continues 
from  one  day  to  eight,  ten,  or  more,  according  to  the  nature  and  ex- 

*  Lister  has  recorded  an  observation  (Phil.  Trans.  1858,  p.  649)  which  shows  very 
clearly  that,  outside  the  body,  the  white  corpuscles  possess  a  greater  amount  of  adhesive- 
ness than  the  red.  If  a  portion  of  blood  be  allowed  to  run  between  two  plates  of  glass 
nearly  in  contact  with  one  another,  the  white  corpuscles  stick  together  near  the  edge  of  the 
glass,  the  red  corpuscles  passing  further  on. 


HEALING     BY    GRAjSTULATION.  153 

tent  of  the  wounded  part,  and  the  general  condition  of  the  body.  In  a 
cut  or  sawn  hard  bone,  about  ten  days  will  generally  elapse  before  any 
change  is  manifest ;  in  cancellous  bone  the  change  ensues  a  few  days 
more  speedily  :  on  the  under  surface  of  a  large  flap  of  skin,  with  sub- 
cutaneous fat,  three  days  may  thus  pass  without  change  ;  on  the  cut 
or  excoriated  surface  of  the  more  vascular  part  of  the  skin,  two  days 
or  three. 

These  periods  of  repose  after  severe  injury  are  of  equal  interest  in 
physiology  and  in  surgery  ;  but  in  the  former  it  is  chiefly  the  interest 
of  mystery.  Observations  on  injuries  of  the  frog's  web*  make  it  pro- 
bable that  the  blood  is  stagnant  in  the  vessels  for  some  little  distance 
from  the  wound  during  several  days  after  the  injury  :  but  why  it  is  so, 
and  what  are  the  changes  ensuing  in  and  about  it  preparatory  to  its 
again  moving  on,  we  cannot  quite  tell.  The  interest  to  the  surgeon 
watching  this  period  of  repose  is  more  practical.  The  calm  may  be 
the  brooding-time  for  either  good  or  evil ;  whilst  it  lasts  the  mode  of 
union  of  the  wound  will,  in  many  cases,  be  determined :  the  healing 
may  be  perfected,  or  a  slow  uncertain  process  of  repair  may  be  but 
just  begun  ;  and  the  mutual  influence,  which  the  injury  and  the  patient's 
constitution  are  to  exercise  on  one  another,  appears  to  be  manifested 
very  often  at  or  near  the  end  of  this  period.  Moreover,  in  open  wounds, 
the  time  at  which,  on  each  tissue,  granulations  are  produced,  is  deter- 
mined by  this  calm ;  for  they  begin  to  be  distinctly  formed  at  its  end. 
Thus,  on  a  stump,  after  a  circular  amputation,  one  may  find  the  mar- 
gin of  the  skin  and  the  surface  of  the  muscles  well  covered  with  granu- 
lations, while  the  surface  of  the  fat  reflected  with  the  skin  is  barren  of 
them,  and  the  sawn  walls  of  the  bone  are  dry  and  bare.  But  from  the 
sawn  end  of  the  medullary  tube  there  may  already  protrude  a  florid 
mushroom-shaped  mass  of  granulations,  overhanging  the  adjacent  walls; 
as  if  parts  in  which  nutrition  is  habitually  carried  on  under  restraint, 
within  hard  and  rigid  boundary-walls,  were  peculiarly  apt  to  produce 
abundant  organizable  material  as  soon  as  they  are  released. f  Grene- 
rally,  also,  the  granulations  springing  from  these  different  tissues  observe 
the  same  order  in  their  rate  of  development  as  in  their  first  appearance. 
Those  that  first  take  the  lead  keep  it,  or,  for  a  time,  increase  it. 

But  suppose  the  period  of  calm  after  the  violence  of  the  injury  to 
be  well  over-past.  How  does  the  right  process  of  repair  set  in  ?  Ap- 
parently, first  of  all,  by  the  supply  of  blood  to  the  injured  part  being 
increased. 

*  See  especially  those  detailed  by  Mr.  Travers  in  his  Essay  on  Inflammation  and  the 
Healing  Process:  and  those  by  Mr.  Wharton  Jones,  On  the  State  of  the  Blood  and  Blood- 
vessels in  Inflammation. 

f  One  may  sometimes  observe  a  similar  fact  in  the  growth  of  granulations  out  of  the  very 
centre  of  the  cut  end  of  a  divided  tendon,  vs^hile  its  margins  are  unchanged.  The  abun- 
dant growth  of  substance  like  brain,  covered  with  granulations,  in  cases  of  hernia  cerebri, 
is  of  the  same  kind. 

11 


154  HEALING    BY    GRANULATION. 

The  experiments  on  the  webs  of  frogs,  to  which  I  have  already  re- 
ferred, have  shown  that,  immediately  after  the  infliction  of  an  injury 
the  blood  in  the  adjacent  parts  remains  for  some  days  quite  stagnant ; 
and  we  may  believe  the  same  occurs,  but  for  a  shorter  time,  in  our  own 
case.  During  this  stagnation,  materials  may  ooze  from  the  vessels, 
enough  to  form  the  glazing  of  the  wounded  surfaces  of  certain  parts  ; 
but  before  granulations  can  be  formed,  the  flow  of  blood  must  again 
begin,  and  its  supply  must  be  increased  by  enlargement,  and  perhaps 
by  multiplication,  of  the  vessels  in  the  injured  part.  We  cannot  often 
see  this  increase  so  well  in  soft  parts  as  in  bone  exposed  after  injury. 
If,  in  this  condition,  compact  bone  be  closely  watched,  there  may  be  seen, 
two  or  three  days  before  the  springing  up  of  granulations,  rosy  points 
or  minute  blotches,  which  gradually  deepen  in  their  hue,  and  become 
larger.  From  these,  presently,  granulations  will  arise.  The  same  pro- 
cess may  be  well  seen  when  a  portion  of  the  skull  has  been  exposed,  as 
by  suppuration  under  the  pericranium.  In  such  a  case,  which  I  watched 
carefully,  nearly  one-third  of  the  upper  part  of  the  skull  was  bared,  and 
it  became  dry  and  yellowish,  and  looked  quite  lifeless ;  but  after  some 
days  a  few  rosy  points  appeared  on  its  surface,  and  these  multiplied  and 
enlarged,  and  from  each  of  them  granulations  grew  up,  till  the  whole 
surface  of  the  skull  was  covered.  I  watched  them  nearly  every  day, 
and  it  seemed  evident,  at  least  to  the  naked  eye,  that,  in  all  cases,  an 
increased  supply  of  blood  preceded  the  production  of  the  new  material 
from  which  granulations  were  to  be  formed. 

Doubtless  just  the  same  happens  in  soft  parts  as  in  bone ;  so  that  it 
may  be  stated,  generally,  that  the  first  visible  change  that  ensues  after 
the  period  of  calm,  the  period  of  incubation,  as  it  is  called,  is  an  in- 
creased supply  of  blood  to  the  parts  in  which  repair  is  to  ensue.  This, 
probably,  corresponds  exactly  with  the  increased  afflux  of  blood  which 
ensues  in  inflammation  ;  and  Mr.  Travers's  and  other  observations  on  the 
healing  of  the  frog's  web,  make  it  nearly-  sure  that  this  increased  afflux 
is  attended  with  slower  movement  of  the  blood,  or  at  first  even  with 
stagnation  of  the  blood  in  the  minute  vessels  nearest  to  the  cut  edges  or 
surface. 

Of  the  force  by  which  this  increased  afflux  of  blood  is  determined,  I 
believe  that  as  yet  no  sufficient  explanation  can  be  rendered  ;  but  the 
fact  serves  to  show  that  the  ordinary  process  of  granulation  is,  in  its 
commencement,  morbid.  It  is  beneficial  indeed,  in  its  end  or  purpose, 
but  is  morbid  in  its  method,  being  comparable  with  the  process  of  in- 
flammation more  than  with  any  of  those  that  are  natural  to  the  body. 
The  process  of  granulating  displays,  I  think,  two  points  of  resemblance 
to  inflammation,  and  of  dissimilarity  from  natural  processes  :  namely, 
1st,  that  the  increased  quantity  of  blood  in  the  part  producing  gra- 
nulations moves  more  slowly  than  in  health ;  while  in  the  naturally  in- 
creased supply  its  movement  is  not  retarded ;  and  2dly,  that  the 
increased  supply  of  blood  precedes  the  increased  production  of  material. 


HEALING    BY    GRANULATION.  l55 

For,  in  the  discharge  of  natural  functions,  the  increased  supply  of  blood 
to  a  part  appears  always  to  be  a  secondary  event,  the  consequence  of 
some  increase  in  the  formation  of  the  part.  As,  in  the  embryo,  many 
parts  form  themselves  before  blood  appears,  and  the  growth  of  these  and 
other  parts  always  a  little  precedes  the  proportionate  supply  of  blood  to 
them  ;  so  always,  subsequently,  the  increase  or  diminution  of  growth, 
or  any  other  organic  act,  appears  to  precede,  by  some  small  interval, 
the  proportioned  change  in  the  supply  of  blood.  But  with  unnatural 
and  morbid  processes  it  appears  to  be  usually  different :  in  these,  with 
inflammation  for  their  type  and  chief  example,  the  increased  afflux  of 
blood  precedes  the  increased  production  of  material  to  be  organized,  and 
the  decrease  of  blood  precedes  the  decrease  of  organic  processes. 

That  which  next  follows,  after  the  increased  afflux  of  blood,  is  the 
effusion  of  the  material  that  is  to  be  organized  into  granulations.  This 
is  added  to,  or,  perhaps,  displaces,  the  glazing  that  already  exists  upon 
some  surfaces ;  and  where  none  such  exists,  as  on  fat  or  bone,  the  new 
material  is  accumulated  on  the  bare  surface  of  the  wound.  No  account 
of  the  process  of  effusion,  so  far  as  it  is  visible  to  the  naked  eye,  can  be 
better  than  Mr.  Hunter's  (iii,  491).  "  I  have  often  been  able,"  he  says, 
"  to  trace  the  growth  and  vascularity  of  this  new  substance.  I  have 
seen  upon  a  sore  a  white  substance,  exactly  similar,  in  every  visible 
respect,  to  coagulating  lymph.  I  have  not  attempted  to  wipe  it  off,  and 
the  next  day  of  dressing  I  have  found  this  very  substance  vascular;  for 
by  wiping  or  touching  it  with  a-  probe  it  has  bled  freely.  I  have  ob- 
served the  same  appearance  on  the  surface  of  a  bone  that  was  laid  bare. 
I  once  scraped  off  some  of  the  external  surface  of  a  bone  of  the  foot,  to 
see  if  the  surface  would  granulate.  I  remarked,  the  following  day,  that 
the  surface  of  the  bone  was  covered  with  a  whitish  substance,  having  a 
tinge  of  blue ;  when  I  passed  my  probe  into  it  I  did  not  feel  the  bone 
bare,  but  only  its  resistance.  I  conceived  this  substance  to  be  coagu- 
lating lymph  thrown  out  from  inflammation,  and  that  it  would  be  forced 
off  when  suppuration  came  on ;  but,  on  the  succeeding  day,  I  found  it 
vascular,  and  appearing  like  healthy  granulations." 

To  this  account  little  can  be  added  more  than  the  microscope  has 
shown.  In  the  minute  structure  of  granulations,  or,  at  least,  of  such 
growths  of  noAV  substance  as  present  all  the  characters  that  we  imply 
by  that  term, — the  bright  ruddy  texture,  the  uniformly  granulated  free 
surface,  the  succulency  and  abundant  supply  of  blood, — in  these  we 
may  discern  two  varieties,  corresponding  with  the  varieties  of  lymph 
that  I  have  already  spoken  of.  In  subcutaneous  injuries  or  diseases, 
granulations  sometimes  form  which  develop  themselves  into  connective 
tissue,  through  nucleated  blastema.  So  I  found  in  a  case  of  simple 
fracture  in  which  the  ends  of  the  bone  remained  long  disunited ;  they 
were  inclosed  in  a  cavity  formed  by  condensation  of  the  surrounding 
tissues,  but  containing  no  pus,  and  were  covered  Avith  a  distinct  layer 


156  HEALING    BY    GRANULATION. 

of  florid  granulations.  It  was  just  such  a  case  as  that  which  Mr.  Hun- 
ter had  in  view,  and  preserved,*  as  an  instance  of  the  formation  of 
granulations  without  suppuration,  in  the  repair  of  subcutaneous  frac- 
tures and  other  injuries. 

But  in  by  far  the  greater  proportion  of  cases,  granulations  are  only 
formed  in  exposed  injuries :  and  in  these,  they  consist  of  cells  that, 
together  with  their  intercellular  substance,  may  develop  themselves 
into  connective  tissue :  and  of  such  as  these  I  will  now  exclusively 
speak. 

Cells  upon  cells,  such  as  I  have  already  described  (p.  140),  are 
heaped  up  together  in  a  layer  from  half  a  line  to  two  lines,  or,  rarely, 
more  in  thickness,  without  apparent  order,  and  connected  by  very  little 
intermediate  substance.  (Figs.  14  and  19.)  Singly  they  are  colorless, 
but  in  clusters  they  are  ruddy  even  independent  of  the  bloodvessels. 
In  granulations  that  are  making  healthy  progress  —  in  such  as,  after 
three  or  four  days'  growth,  are  florid,  moist,  level,  scarcely  raised  above 
the  surrounding  tissues,  uniformly  granular,  or  like  a  surface  of  minute 
papillas, — one  can  conveniently  trace  the  cells  in  various  stages,  ac- 
cording to  the  position  they  occupy.  The  deeper  seated  ones  are 
always  most  advanced,  and  often  much  elongated  and  fusiform ;  while 
the  superficial  ones  are  still  in  a  rudimental  state,  or,  near  the  edges  of 
the  granulating  surface,  are  acquiring  the  character  of  epithelial  cells. 

The  connective  tissue  thus  constructed  by  the  development  of  the 
granulation-cells,  and  their  intermediate  substance,  finally  assumes  all 
the  characters  of  the  natural  examples  of  that  tissue.  Thus  it  is  found 
in  the  thin  layer  of  substance  of  which  scars  that  are  formed  in  the 
place  of  granulating  wounds,  are  composed.  After  some  time,  elastic 
tissue  is  mingled  with  the  white  fibrous  ;  but  this,  as  I  have  already 
said,  appears  to  be  effected  by  a  later  process.  I  found,  in  one  case, 
no  elastic  tissue  in  scars  that  had  existed,  the  one  twelve  months,  the 
other  eighteen  months ;  but  in  scars  several  years  old  I  have  always 
found  it. 

The  cuticle,  also,  that  forms  on  granulations,  gradually  approximates 
more  nearly  to  the  perfect  characters,  and,  like  the  connective  tissue 
that  it  covers,  presents  the  interesting  fact  of  adaptation  to  the  pur- 
poses of  the  part  on  which  it  is  placed.  Thus,  in  granulating  wounds 
or  ulcers  on  the  sole  of  the  foot,  one  may  often  see  that,  from  the  first, 
the  new  cuticle  is  more  opaque  and  thicker  than  it  is  on  other  parts  on 
which  the  natural  cuticle,  in  adaptation  to  the  protection  required  from 
it,  is  naturally  thinner ;  and  let  it  be  observed  that  this  peculiar  forma- 
tion of  the  new  cuticle  is  in  adaptation  to  conditions  not  yet  entered 
upon.  It  justly  excited  the  admiration  of  Albinusf  when  he  saw  in 
the  foetus,  even  long  before  birth,  the  cuticle  of  the  heel  and  palm 
thicker  than  those  of  other  parts ;  adapted  and  designed  to  that  greater 

*  College  Museum,  No.  16.  -j-  Annotationes  Academicse. 


HEALING    BY    GRANULATION.  157 

friction  and  pressure,  to  which,  in  future  time,  they  would  be  exposed. 
It  is  the  same  when,  in  adult  life,  the  new  cuticle  is  to  be  formed  on 
the  same  parts.  While  it  is  forming,  all  pressure  and  all  friction  are 
kept  away,  yet  it  is  constructed  in  adaptation  to  its  future  exposure  to 
them.  Surely  such  a  provision  is,  beyond  all  refutation,  an  evidence 
of  design ;  and  surely  in  this  fact  we  may  discern  another  instance  of 
the  identity  in  nature  and  in  method  of  the  powers  that  are  put  in 
operation  in  the  acts  of  first  construction  and  of  repair. 

But  before  I  end  this  lecture,  let  me  add,  that  although  one  may  so 
clearly  trace,  in  the  development  of  the  granulation-cells,  an  interme- 
diate substance,  and  in  the  end.  which  they  achieve  by  the  formation  of 
connective  tissue  and  cuticle,  an  imitation  of  the  natural  processes  and 
purpose  of  the  corresponding  developments  in  the  embryo,  yet  is  there  a 
remarkable  contrast  between  them,  in  regard  to  the  degrees  in  which 
they  are  severally  liable  to  defect  or  error.  We  can  scarcely  find  ex- 
amples of  the  arrests  or  errors  of  development  of  mere  structure  in  the 
embryo  ;  but  such  events  are  quite  common  in  the  formation  of  granu- 
lations, as  well  as  of  all  other  new  products.  All  the  varieties  in  the 
aspect  of  granulating  wounds  and  sores,  which  the  practised  eye  can 
recognize  as  signs  of  deflection  from  the  right  way  to  healing,  are  so 
many  instances  of  different  diseases  of  the  granulation-substance  ;  dis- 
eases not  yet  enough  investigated,  though  of  much  interest  in  the  study 
of  both  the  healing  process  and  the  organization  of  new  products  in 
inflammation. 

A  comparatively  few  observations  enable  one  to  trace  morbid  condi- 
tions of  these  new  structures,  closely  answering  to  those  long  known  in 
the  older  and  more  perfect  tissues.  Thus,  one  may  find  simply  arrested 
development  of  granulations  ;  as  in  the  indolent  healing  of  wounds  and 
ulcers,  whether  from  locally  or  generally  defective  conditions.  Herein 
even  years  may  pass,  and  the  cells  will  not  develop  themselves  beyond 
one  or  other  of  their  lower  forms.  There  is  probably  a  continual  mu- 
tation of  particles  among  such  cells,  as  in  common  nutrition,  or  they 
may  increase,  as  in  growth ;  but  no  development  ensues,  and  the  wound 
or  the  ulcer  remains  unhealed. 

In  other  cases,  the  cells  not  only  do  not  develop  themselves,  but  they 
degenerate,  becoming  more  granular,  losing  the  well-marked  characters 
of  their  nucleus,  and  acquiring  all  the  structures  of  the  pus-cell ;  thus 
are  they  found  in  the  walls  of  the  fistulge  and  sinuses.  Or,  worse  than 
this,  the  granulation-cells  may  lose  all  structure,  and  degenerate  into  a 
mere  layer  of  debris  and  molecular  substance.  Thus  they  may  be  found 
on  the  surface  of  a  wound  for  a  day  or  so  before  death  in  exhaustion, 
or  in  erysipelas,  or  fever  ;  and  in  this  state  they  are  commonly  ejected 
when  a  granulating  wound  ulcerates  or  sloughs. 

With  more  active  disease,  granulations  become  turgid  with  blood,  or 
oedematous  :  such  are  the  spongy  masses  that  protrude  beyond  the  open- 
ings leading  to  diseased  bone.      Or,  they  inflame ;  and  abundant  large 


158  FORMATION    OF    NEW    BLOODVESSELS. 

inflammatorv  granule-cells  are  found  among  their  proper  structures. 
Or  they  suppurate  internally,  and  purulent  infiltration  pervades  their 
whole  mass. 

All  these  are  among  the  many  hindrances  to  healing :  these  are  the 
dangers  to  which  the  healing  by  granulations  is  obnoxious :  it  is  the 
proneness  to  these  things  that  makes  it  even  slower  and  more  insecure 
than,  in  its  proper  course,  it  might  be.  And  these  are  all  instances  of 
a  class  of  changes  which  it  is  most  important  to  study  for  exactness  in 
morbid  anatomy, — I  mean,  the  diseases  of  the  products  of  disease. 


LECTURE    X. 

THE    PROCESSES    OF    REPAIR    OF    WOUNDS. 

With  the  structural  development  of  the  granulation-cells  and  inter- 
mediate substance  into  connective  tissue  and  cuticle,  as  described  in  the 
last  lecture,  there  coincides  a  chemical  change  which  seems  to  be  the 
contrary  of  development ;  for  the  granulation-substance,  being  con- 
verted from  albuminous  into  horny  and  gelatinous  principles,  becomes, 
in  chemical  composition,  less  remote  than  it  was  from  the  constitution 
of  inorganic  matter.  At  its  first  effusion,  the  reparative  material  has 
the  characters  of  a  fibrinous  principle  ;  afterwards,  when  in  the  form  of 
granulations  and  of  young  connective  tissue,  its  reactions  are  so  far 
altered  that  it  presents  the  characters  of  pyine,  a  somewhat  indefinite 
principle,  yet  an  albuminous  one ;  finally  in  its  perfect  development, 
the  new-formed  connective  tissue  is  gelatinous,  and  the  epithelium  ap- 
pears to  be  like  other  specimens  of  horny  matter. 

These  changes  are  in  conformity  with  what  appears  to  be  a  general 
rule ;  namely,  that  structures  which  are  engaged  in  energetic  develop- 
ment, self-multiplying,  the  seat  of  active  vital  changes,  are  generally  of 
the  highest  organic  chemical  composition  ;  while  the  structures  that  are 
already  perfect,  and  engaged  in  the  discharge  of  functions  such  as  are 
attended  with  infrequent  changes  of  their  particles,  are  as  generally  of 
lower  composition.  The  much  higher  chemical  development  (if  I  may 
so  call  it)  of  the  blood,  than  of  the  greater  part  of  the  tissues  that  are 
formed  from  it,  is  a  general  instance  of  this  :  in  it  albumen  and  fibrine 
predominate,  and  there  is  no  gelatine  ;  in  the  tissues  gelatine  is  abun- 
dant, and  fatty  matter :  and  both  these,  through  their  afiinities  to  the 
saccharine  and  oily  principles,  approach  the  characters  of  the  lower 
vegetable  and  inorganic  compounds. 

The  granulation-substance  is  a  good  instance  in  point :  while  lowly 
developed,  but  in  an  active  vegetative  life,  it  is  albuminous  ;  when  per- 
fect in  its  development,  its  perfected  structures  are  gelatinous  or  horny. 


FORMATION    OF    NEW    BLOODVESSELS.  159 

In  this  state  its  particles  have  probably  a  longer  existence  ;  they  ex- 
change a  brief  life  of  eminence  for  longevity  in  a  lower  station. 

I  have  spoken  hitherto  of  the  development  of  only  those  structures 
which  form  the  proper  material  of  granulations,  and  of  the  scars  that 
remain  after  the  healing  of  wounds.  But  commensurately  with  these, 
bloodvessels,  and,  perhaps,  also,  nerves,  are  formed.  Of  these,  there- 
fore, I  will  now  speak. 

In  the  last  lecture  I  referred  to  the  changes  that  ensue  in  the  circu- 
lation of  a  wounded  part.  At  first,  it  appears  that  the  blood  stagnates 
in  the  vessels  immediately  adjacent  to  the  wound.  This  is  evident  in 
the  wounds  made  in  frogs'  webs,  and  is  most  probable  in  the  case  of 
wounds  in  our  own  tissues ;  for  else  we  could  hardly  understand  the 
total  absence  of  bleeding  from  a  surface  on  which,  as  in  every  large 
wound,  myriads  of  small  vessels  must  be  cut,  and  lie  exposed.  But 
after  a  time,  of  various  duration  in  the  different  tissues,  the  movement 
of  the  blood  is  renewed,  though  not  to  its  former  velocity  ;  the  vessels  of 
the  wounded  parts  enlarge,  and  they  all  appear  more  vascular.  Then 
the  material  of  granulations,  already  in  part  effused,  accumulates,  and 
very  soon  blood  and  bloodvessels  appear  in  this  material. 

By  what  process  are  these  new  vessels  formed  ?  Mr.  Hunter's  opi- 
nion was  (and  it  is  still  held  by  many),  that  both  the  blood  and  its  ves- 
sels form  in  the  granulation-substance,  as  they  do  in  the  germinal  area 
of  the  chick ;  and  that,  subsequently,  they  enter  into  communications 
with  the  vessels  and  blood  of  the  part  from  which  the  granulations 
spring.  This  is  certainly  not  proved :  although  the  development  of 
the  new  vessels  is  according  to  a  method  that  is  equally  natural. 

In  embryos,  we  may  discern  three  several  modes  according  to  which 
bloodvessels  are  formed,  a  good  example  of  the  manifold  ways  by  which, 
in  development,  the  same  end  may  be  reached.  In  the  first  and  earli- 
est method  solid  cylinders  of  round  cells,  lying  compactly  together,  are 
formed  in  the  area  vasculosa,  in  which  cylinders  changes  then  take 
place.  The  cells  in  the  central  part  of  the  cylinder  loosen  and  become 
converted  into  blood-corpuscles,  or,  as,  Billroth*  appears  to  think,  their 
membranes  disappear,  and  their  contents  only  constitute  the  blood-cor- 
puscles. The  membranes  of  the  cells  on  the  outer  parts  of  the  cylinder 
coalesce  and  form  the  membranous  wall  of  the  vessel,  which  may  after- 
wards be  developed  into  the  more  complicated  structures  of  the  heart, 
or  larger  bloodvessels.  To  increase  the  extent  and  number  of  vessels 
that  must  be  added  in  adaptation  to  the  enlargement  and  increasing 
complexity  of  the  embryo,  two  methods  are  observed.  In  one,  primary 
cells,  in  the  interspaces  of  vessels  already  existing,  enlarge  and  elongate, 
and  send  out  branches  in  two  or  more  directions,  so  as  to  assume  a  stel- 
late form.     These  branches  are  hollow  :  and  while  some  of  them  are 

*  Untersuchungen  iiber  die  Entwicklung  der  Blutgefasse;  Berlin,  1S56. 


160 


PORMATION     OF    NEW    BLOODVESSELS. 


directed  into  anastomosis  with  each  other,  others  extend  towards,  and 
open  Avith  dilatations  into,  the  vessels  already  formed  and  carrying 
blood.  Then,  these  fine  branches  of  each  cell  becoming  larger,  while 
the  main  cavity  of  the  cell,  from  which  they  issued,  attenuates  itself, 
they  are  altogether  transformed  into  a  network  of  tubes  of  nearly  uni- 
form calibre,  through  which  the  blood,  entering  by  the  openings  of 
communication  with  the  older  vessels,  makes  its  way.  Thus  the  wide 
network  formed  in  the  primordial  circulation  is  subdivided  into  smaller 
meshes,  and  each  part  receives  a  more  abundant  supply  of  blood.  Bill- 
roth has  described  a  kind  of  vascular  formation,  which  may  be  considered 
as  a  modification  of  the  above  method.  He  has  seen  long  spindle-like 
cells  lie  with  their  long  axes  parallel  to  each  other  and  close  together, 
but  not  in  cojitact,  so  that  a  fine  canal  existed  between  them,  which 
constituted  the  canal  of  the  newly  formed  vessel,  the  wall  being  formed 
by  the  spindle-like  cells  themselves.  From  these  cells  new  blood-cor- 
puscles proceeded  into  the  vessel,  as  in  the  first  method  of  vascular 
formation.  This  process  he  has  noticed  not  only  in  embryonic  tissues, 
but  also  in  granulations. 

The  other  of  these  secondary  modes  of  formation  of  new  bloodves- 
sels is,  I  believe,  the  most  frequent  mode  in  which  bloodvessels  are  ever 
formed  for  granulations,  or  for  superficial  deposits  of  lymph,  adhesions, 

and   the  like.      The   dia- 
^ig-  16.  gram  is  made  from  what 

may  be  seen  in  the  grow- 
ing parts  of  the  tadpole's 
tail,  and  it  accords  with 
what  Spallanzani  observed 
of  the  extension  of  vessels 
into  the  substance  of  the 
tail  when  being  reproduced 
after  excision.  Mr.  Tra- 
vers*  and  Mr.  Quekett 
watched  the  same  process 
in  the  new  material  formed 
for  the  filling  up  of  holes  made  in  the  frog's  web;  and  the  same  is  in- 
dicated in  the  specimens  illustrating  the  repair  of  similar  wounds  which 
are  in  the  College,  from  the  Museum  of  the  late  Dr.  Todd,  of  Brigh- 
ton. There  is,  I  think,  sufiicient  reason  to  suppose  that  it  is  the 
principal  method  for  the  supply  of  bloodvessels  to  any  granulations,  or 
similar  new  productions.  For,  though  the  process  in  granulations  or 
in  lymph  cannot  be  exactly  watched  during  life,  yet  every  appearance 
after  death  is  consistent  with  the  belief  that  it  is  the  same  as  has  been 
traced  in  the  cases  I  have  cited,  and  I  have  never  seen  any  indications 
of  either  of  the  other  methods  of  development  having  occurred. 


*  On  Inflammation,  and  the  Healing  Process.     See,  also,  on  a  similar  formation,  Virchow 
in  the  Wiirzburg  Verhandhmgen,  B.  i,  p.  301. 


FORMATION  OF  NEW  BLOODVESSELS.  161 

The  method  may  be  termed  that  by  out-growth  from  the  vessels  al- 
ready formed.  Suppose  a  line  or  arch  of  capillary  vessel  passing  below 
the  edge  or  surface  of  a  part  to  Avhich  new  material  has  been  superadded. 
(Fig.  16.)  The  vessel  will  first  present  a  dilatation  at  one  point,  and 
coincidently,  or  shortly  after,  at  another,  as  if  its  wall  yielded  a  little 
near  the  edge  or  surface.  The  slight  pouches  thus  formed,  gradually 
extend,  as  blind  canals,  or  diverticula,  from  the  original  vessel,  still 
directing  their  course  towards  the  edge  or  surface  of  the  new  material, 
and  crowded  with  blood-corpuscles,  which  are  pushed  into  them  from 
the  main  stream.  Still  extending,  they  converge ;  they  meet ;  the  par- 
tition wall,  that  is  at  first  formed  by  the  meeting  of  their  closed  ends, 
clears  away,  and  a  perfect  arched  tube  is  formed,  through  which  the 
blood,  diverging  from  the  main  or  former  stream  and  then  rejoining  it, 
may  be  continuously  propelled.  Or  a  delicate  thread-like  process  shoots 
out  from  a  vessel,  which  becomes  connected  either  with  corresponding 
shoots  from  other  vessels,  or  with  processes  from  other  cells.  These 
fine  processes  widen  out,  become  tubular,  and  their  cavities  form  canals 
continuous  with  that  of  their  parent  vessel.* 

In  this  way,  then,  are  the  simplest  bloodvessels  of  granulations  and 
the  like  out-growths  formed.  The  plan  on  which  they  are  arranged  is 
made  more  complex  by  the  similar  out-growths  of  branches  from  adja- 
cent arches,  and  their  mutual  anastomoses  :  but,  to  all  appearance,  the 
whole  process  is  one  of  out- growth  and  development  from  vessels  already 
formed.  And  I  beg  of  you  to  consider  the  wonder  of  such  a  process  ; 
how,  in  a  day,  a  hundred  or  more  of  such  loops  of  fine  membranous 
tube,  less  than  y^'^^th  of  an  inch  in  diameter,  can  be  upraised ;  not  by 
any  mere  force  of  pressure,  though  with  all  the  regularity  of  the  sim- 
plest mechanism,  but  each  by  a  living  growth  and  development,  as  or- 
derly and  exact  as  that  which  we  might  trace  in  the  part  most  essential 
to  the  continuance  of  life.  Observe,  that  no  force  so  simple  as  even 
that  of  mere  extension  or  assimilation  can  determine  such  a  result  as 
this  :  for,  to  achieve  the  construction  of  such  an  arch,  it  must  spring 
Avith  due  adjustment  from  two  determined  points,  and  then  its  flanks 
must  be  commensurately  raised,  and  these,  as  with  mutual  attraction, 
must  approach  and  meet  exactly  in  the  crown.  Nothing  could  accom- 
plish such  a  result  but  forces  determining  the  concurrent  development 
of  two  out-growing  vessels.  We  admire  the  intellect  of  the  engineer, 
who,  after  years  of  laborious  thought,  with  all  the  appliances  of  weight 
and  measure  and  appropriate  material,  can  begin  at  points  wide  apart, 
and  force  through  the  solid  masses  of  the  earth  one  tunnel,  and  can 
wall  it  in  secure  from  external  violence,  and  strong  to  bear  some  pon- 
derous traffic  ;  and  yet  he  does  but  grossly  and  imperfectly  imitate  the 
Divine  work  of  living  mechanism  that  is  hourly  accomplished  in  the 
bodies  of  the  least  conspicuous  objects  of  creation — nay,  even  in  the 
healing  of  our  casual  wounds  and  sores. 

*  Billroth,  op.  cit. 


162 


FORMATION    OF    NEW    BLOODVESSELS. 


riff.  17. 


The  wonder  of  the  process  is,  perhaps,  in  some  degree  enhanced  by 
the  events  that  will  follow  what  may  seem  to  be  an  accident.  When 
the  new  vessel  has  begun  to  project,  it  sometimes  bursts;   and  the 

diagram  shows  what  then 
will  happen,  I  have  to 
thank  Mr.  Quekett  for  the 
sketch,  which  he  made  while 
assisting  Mr.  Travers  in  the 
examinations  already  cited. 
The  blood-corpuscles  that  is- 
sue from  the  ruptured  pouch 
or  diverticulum  collect  in  an 
uncertain  mass  within  the 
tissue,  like  a  mere  ecchymosis ;  but,  before  long,  they  manifest  a  defi- 
nite direction,  and  the  cluster  bends  towards  the  line  in  which  the  new 
vessel  might  have  formed,  and  thus  opens  into  the  other  portion  of  the 
arch,  or  into  some  adjacent  vessel.  For  this  mode  of  formation  from 
vessels,  the  name  of  channelling  seems  more  appropriate  than  that  of 
out-growth ;  for  it  appears  certain  that  the  blood- corpuscles  here  make 
their  way  in  the  parenchyma  of  the  tissue,  unconfined  by  membranous 
walls.  That  they  do  so  in  a  definite  and  purposive  manner,  though 
their  first  issue  from  the  vessel  has  appeared  so  accidental,  may  be  due 
to  the  fact  that  in  the  more  regular  development  by  out-growth,  the 

cells  of  the  parenchyma  concur 
with  the  extension  of  the  new 
vessels,  by  clearing  away  from 
them  as  they  approach ;  so  that, 
even  before  the  out-growth,  the 
way  for  it  or  for  its  contents 
(should  they  happen  to  escape), 
is,  in  some  measure  determined.* 
The  general  plan  of  arrange- 
ment of  the  bloodvessels  in  gra- 
nulations, represented  in  the  ad- 
joining sketch,  agrees  with  this 
account  of  their  development  by 
out-growth.  Some  of  Sir  A. 
Cooper's  preparations  in  the 
Museum  of  the  Collegef  show 
how  the  new  vessels  extend  from 

*  Billroth  has  described  and  figured  (p.  15,  PI.  i,  Fig.  21)  an  appearance  very  similar  to 
that  recorded  in  the  text.  He,  at  first,  thought  that  it  was  simply  an  extravasation,  but 
further  consideration  has  led  him,  in  accordance  with  certain  views  which  he  entertains 
respecting  the  mode  of  formation  of  blood-corpuscles,  to  think  that  here,  perhaps,  a  new 
free  formation  of  colored  blood-corpuscles,  out  of  the  colorless-shining  homogeneous  cells  of 
the  part  takes  place.  At  the  same  time  he  confesses  the  difficulty  of  understanding  how 
they  get  into  the  circulation. 

f  Nos.  19,  20,  356. 


Pii?.  18. 


FORMATION    OF    NEW    BLOODVESSELS. 


163 


the  parts  on  which  the  granulations  lie,  in  lines  directed  vertically 
towards  their  surface,  not  often  dividing,  but  communicating  on  their 
way  by  frequent  transverse  or  irregular  branches.  Of  these  branches, 
some  probably  represent  the  loops  or  arches  successively  formed  in  the 
deepening  layer  of  granulation-cells,  while  others  must  be  formed  by 
oifshoots  from  the  sides  and  other  parts  of  the  several  arches.  Near 
the  surface  of  the  granulations,  at  a  very  little  distance  below  the  outer- 
most layer  of  the  cells,  the  vessels  communicate  much  more  frequently, 
and  form  their  loops  or  terminal  arches — arches  of  junction  between  the 
outgoing  and  the  returning  streams  of  blood. 

On  the  same  plan  are  formed  the  vessels  of  the  walls  of  abscesses 
lined  with  granulations  ;  but  here  (at  least  in  the  specimens  I  have 
been  able  to  examine)  the  vertical  vessels  are  not  so  long,  and  the 
whole  number  of  vessels  is  generally  greater.  I  believe  the  vessels  of 
granulating  ulcers  are  always  similarly  arranged ;  so  they  are  repre- 
sented by  Mr.  Liston,*  in  a  common  ulcer ;  so,  also,  Sir  A.  Cooperf 
described  them  in  granulations  from  an  ulcerated  scirrhous  cancer ;  and 
I  have  found  the  same  general  plan  m  the  warty  ulceration  of  soot- 
cancer  on  the  scrotum. 

The  new  vessels  formed  in  granulations  possess  a  very  simple  struc- 
ture. Their  walls  consist  of  a  thin  membrane  in  which  nuclei  are  im- 
bedded. Some  of  these  nuclei  are  arranged  longitudinally,  others  trans- 
versely, to  the  axis  of  the  vessels,  and  it  is  often  noticeable  that  the 
development  of  the  tissues  of  the  bloodvessels  makes  more  progress  than 
that  of  the  granulation-cells  which  they  subserve. 

Respecting  the  purpose  of  the  supply  of  blood  thus  sent  to  granula- 
tions, one  traces,  in  the  development  of  vessels,  a  series  of  facts  exactly 
answering  to  those  in  ordinary  em- 
bryonic development.  Organiza- 
tion makes  some  progress  before 
ever  blood  comes  to  the  very  sub- 
stance of  the  growing  part ;  for 
the  form  of  cells  may  be  assumed 
before  the  granulations  become 
vascular.  But,  for  their  continu- 
ous active  growth  and  develop- 
ment, fresh  material  from  blood, 
and  that  brought  close  to  them, 
is  essential.  For  this,  the  blood- 
vessels are  formed;  and  their  size 
and  number  appear  always  pro- 
portionate to  the  volume  and 
rapidity  of  life  of  the  granula- 
tions.    No  instance  would  show 


Fiff.  19. 


*  Medico-Chirurgical  Transactions,  vol.  xxiii,  p.  S5. 

f  Catalogue  of  the  Pathological  Museum  of  the  College,  vol.  i,  p.  111. 


164  FORMATION    OF    NEW    BLOODVESSELS.  fssassm' 

■I' 

the  relation  of  blood  to  an  actively  growing  or  developing  part  better 
than  it  is  shown  in  one  of  the  vascular  loops  of  a  granulation,  imbedded, 
as  this  sketch  shows  it,  among  the  crowd  of  living  cells,  and  maintaining 
their  continual  mutations.  Nor  is  it  in  any  case  plainer  than  in  that 
of  granulations,  that  the  supply  of  blood  in  a  part  is  proportionate  to 
the  activity  of  its  changes,  and  not  to  its  mere  structural  development. 
The  vascular  loops  lie  imbedded  among  the  simplest  primary  cells,  or, 
when  granulations  degenerate,  among  structures  of  yet  lower  organiza- 
tion; and  as  the  structures  are  developed,  and  connective  tissue  formed, 
so  the  bloodvessels  become  less  numerous,  till  the  whole  of  the  new 
material  assumes  the  paleness  and  low  vascularity  of  a  common  scar.* 
But,  though  the  quantity  of  bloodvessels  is  determined  by  the  state  of 
the  substance  they  supply,  the  development  of  their  tissues  has  no  such 
relation.  It  is  often  complete  'while  the  granulation-cells  are  rudimen- 
tal,  and  remains  long  unchanged  when  they  are  degenerate.  The  fact 
may  be  regarded  as  evidence  of  the  formation  of  the  new  bloodvessels 
by  out-growth  from  the  older  ones ;  for  it  is  not  probable  that  well-de- 
veloped bloodvessels  and  ill-developed  granulation-cells  should  be  formed 
out  of  the  same  materials  at  the  same  time. 

Of  the  development  of  Nerves  in  granulations  I  know  nothing  ;  I  have 
never  been  able  to  see  any  in  either  granulations  or  cicatrices.  The  ex- 
quisite pain  sometimes  produced  by  touching  granulations  would  indi- 
cate the  presence  of  nerves :  but  it  would  be  more  satisfactory  to  see 
them  ;  for  the  force  of  contact,  or  the  change  that  it  produces,  may  be 
propagated  through  the  layer  of  granulations,  and  stimulate  the  nerves 
beneath  them,  as  contact  with  the  exterior  of  a  tooth  excites  the  nerve- 
filaments  in  its  pulp.  The  sensibility  that  granulations  seem  to  have 
may,  therefore,  be  really  that  of  the  tissues  from  which  they  spring. 

Lymphatics  do  not  exist  in  granulations.  Professor  Schroeder  van 
der  Kolk  has  demonstrated  them  in  false  membranes  by  mercurial  in- 
jections (Fig.  35)  :t  but  in  a  letter  he  tells  me  that  they  cannot,  either 
by  these  or  by  any  other  means,  be  traced  in  either  scars  or  granulations ; 
and,  he  adds,  ''  they  cannot  be  demonstrated  in  the  skin,  even  in  the 
healthy  state,  except  in  the  scrotum." 

The  subject  of  suppuration  should  perhaps  be  considered  now  ;  but 
I  had  rather  defer  it  till  I  have  spoken  briefly  of  the  two  remaining 
modes  of  healing  open  wounds ;  those,  namely,  by  secondary  adhesion, 
and  by  scabbing. 

*  Billroth  (Beitrage  zur  Path.  Hist.)  describes  the  group  of  cells  situated  around  a  capil- 
lary loop  on  a  granulating  surface,  as  formed  by  the  proliferation,  by  division  of  the  nuclei, 
of  the  adjacent  connective-tissue  corpuscles.  C.O.Weber  (Entvi^icklung  des  Eiters),  re- 
ferring to  Fig.  19  in  this  Lecture,  states  that  the  delicate  cells  which  surround  the  vascular 
loops  of  a  granulating  surface  are  of  a  spindle-like  shape,  and  are  imbedded  in  a  thick  layer 
ol  growing  connective-tissue  nuclei. 

f  Lespinasse,  De  Vasis  Novis  Pseudo-membranarum,  figs,  iii,  v. 


HEALING    BY     SECONDAKT    ADHESION.  165 

The  healing  by  secondary  adhesion,  or  union  of  granulations,  has  been 
long  and  often  observed ;  yet  it  has  been  only  casually  described,  and 
having  never  been  distinguished  by  a  specific  name,  has  not  received 
that  attention  to  which  its  importance  in  practice  seems  to  entitle  it. 
It  occurs  wherever  surfaces  of  granulations,  formed  in  the  manner  just 
described,  well-developed,  but  not  yet  covered  with  cuticle,  are  brought 
into  contact,  and  so  retained  at  rest.  As  often  as  this  happens,  the 
cells  of  which  the  surfaces  are  composed  adhere  together ;  vessels 
passing  through  them  form  mutual  communications  ;  and  the  surfaces, 
before  separate,  are  connected  ;  out  of  the  two  layers  of  granulations, 
one  is  formed,  which  pursues  the  normal  development  into  connective 
tissue. 

In  all  its  principal  characters,  therefore,  the  process  of  secondary  ad- 
hesion is  like  that  adhesion  for  which,  to  mark  at  once  their  likeness 
and  their  differences,  I  have  suggested  the  term  of  primary.  In  the 
primary  adhesion,  the  layer  of  lymph,  placed  between  the  wounded  and 
bare  surfaces,  is  probably  formed  equally  and  coincidently  from  both ; 
and,  being  developed  in  the  same  manner  as  the  granulations,  of  which 
I  have  spoken,  it  probably  receives  vessels  from  both  surfaces,  and  so 
becomes  the  medium  through  which  the  vessels  communicate  and  com- 
bine the  severed  parts.  In  the  process  of  secondary  adhesion,  the 
superficial  cells  on  the  surfaces  of  two  layers  of  granulations  are  placed 
together,  and  receiving  vessels  from  both  combine  them  into  one. 

Mr.  Hunter  observed  this  process,  and  says  of  it, — "  Granulations 
have  the  disposition  to  unite  with  one  another  when  sound  or  healthy  ; 
the  great  intention  of  which  is  to  produce  the  union  of  parts,  somewhat 
similar  to  that  by  the  first  intention,  although  possibly  not  by  the  same 
means."  And  "I  have  seen  two  granulations  on  the  head, — viz.,  one 
from  the  dura  mater  after  trepanning,  and  the  other  from  the  scalp, 
unite  over  the  bare  bone  which  was  between  them,  so  strongly,  in  twenty- 
four  hours,  that  they  required  some  force  to  separate  them,  and  when 
separated  they  bled."* 

In  illustration  of  this  process  he  put  up  a  preparationf  which  in  his 
MS.  Catalogue  he  describes  as  "granulations  under  the  skin  in  an  ab- 
scess in  the  leg,  which  were  opposed  by  others  on  the  muscles,  and 
which  were  to  unite.  Those  under  the  skin  only  are  saved  and  folded 
towards  each  other,  to  show  the  opposition  of  two  granulating  sur- 
faces." 

There  are  several  circumstances  in  which  the  healing  by  secondary 
adhesion  should  be  attempted.  For  example,  in  a  case  of  ordinary  am- 
putation of  the  thigh,  no  immediate  union,  and  no  primary  adhesion, 
took  place,  after  the  operation,  and  the  whole  interior  of  the  stump  was 
granulating.  Had  it  been,  as  the  expression  is,  "left  to  granulate," 
or  "to  fill  up  with  granulations,"  the  healing  process  would  have  occu- 

*  Works,  vol.  iii,  p.  493.  f  Pathological  Museum  of  the  College,  No.  27. 


166  ■  HEALING    UNDER    A    SCAB. 


I 


pied  at  least  a  month  or  five  weeks  more,  and  would  have  greatly  ex- 
hausted the  patient,  already  weakened  by  disease.     But  Mr.  Stanley 
ordered  the  stump  to  be  so  bandaged  that  the  opposite  surfaces  of  gra-  m 
nulations  might  be  brought  into  close   contact :  they  united,  and  in  a 
week  the  healing  of  the  stump  was  nearly  perfected. 

In  all  such  cases,  and  I  need  not  say  that  they  are  very  frequent,  the 
healing  by  secondary  adhesion  may  be  attempted  without  danger,  and 
often  with  manifest  advantage. 

Again  :  Mr.  Hunter  operated  for  hare-lip,  and  no  primary  adhesion 
of  the  cut  surfaces  ensued.  He  let  them  both  granulate  :  then  brought 
the  granulations  together,  as  in  the  common  operation,  and  they  united, 
and  healed  soundly. 

Or,  again  :  Mr.  Skey,  some  time  ago,  operated  for  fissure  of  the  soft 
palate.  The  edges  of  the  wound  sloughed  and  retracted,  and  the  case 
seemed  nearly  hopeless  ;  but  he  kept  in  the  sutures,  and  granulations 
sprang  up  from  the  edges  of  the  cleft,  after  the  separation  of  the  sloughs  ; 
they  met  in  the  mid-space  of  the  cleft,  and  coalesced,  and  formed  a  per- 
fect scar. 

Doubtless,  cases  like  these  are  of  no  rare  occurrence ;  but  I  am  in- 
duced to  mention  them,  as  illustrations  of  a  process  of  which  the  im- 
portance and  utility  are  not  generally  considered,  and  which  is  rarely 
applied  in  practice. 

In  applying  it,  certain  conditions  are  essential  to  success ;  especially 
that, — 1st,  the  granulations  should  be  healthy,  not  inflamed,  or  pro- 
fusely suppurating  or  degenerated,  as  those  in  sinuses  commonly  are : 
2dly,  the  contact  between  them  should  be  gentle  but  maintained  ;  and 
perhaps  they  should  be  as  much  as  possible  of  equal  development  and 
age. 

The  healing  of  wounds  by  scabbing  may  be  regarded,  as  Mr.  Hunter* 
says,  as  the  natural  one,  for  it  requires  no  art.  It  is  the  method  by 
which  one  sees  nearly  all  open  wounds  healed  in  animals :  for  in  them, 
even  in  the  warm-blooded,  it  is  difiicult  to  excite  free  suppuration  from 
the  surfaces  of  wounds :  they  quickly  become  coated  with  a  scab,  formed 
of  the  fluids  that  ooze  from  them  and  entangle  dust  and  other  foreign 
bodies ;  and  under  such  a  scab  the  scar  is  securely  formed. 

In  general,  the  scabbing  process  is  effected  by  some  substance  which 
is  eff"used  on  the  surface  of  the  wound,  dries  there,  and  forms  a  hard 
and  nearly  impermeable  layer.  The  edges  of  this  substance  adhere 
over  those  of  the  Avound,  so  as  to  form  for  it  a  sort  of  air-tight  covering, 
under  which  it  heals  without  suppuration,  and  with  the  formation  of  a 
scar,  which  is  more  nearly  like  the  natural  parts  than  any  scars  formed 
in  wounds  that  remain  exposed  to  the  air,  and  which  does  not,  like 
them,  contract,  so  as  to  produce  deformity  of  the  parts  about  it. 

*  Works,  vol.  iii,  262. 


HEALING    UNDER    A    SCAB.  167 

The  scab  may  be  formed  of  either  dried  blood,  dried  lymph  and 
serum,  or  dried  purulent  fluid.  Instances  of  the  healing  of  wounds 
under  dried  blood  are  not  rare.  It  is  especially  apt  to  occur  in  the 
cases  of  wounds  in  which  a  large  flat  surface  is  exposed,  as  after  the 
removal  of  the  breast  with  much  integument.  The  most  remarkable 
case  of  this  kind  is  recorded  by  Mr.  Wardrop.*  The  largest  wounded 
surface  he  ever  saw,  remaining  after  the  removal  of  a  diseased  breast, 
almost  entirely  healed  under  a  crust  of  blood,  which  remained  on  for 
more  than  thirty  days.f  But  the  most  common  examples  of  healing 
under  blood-scabs  are  in  small  wounds,  such  as  are  made  in  bleeding, 
or  more  rarely  in  some  compound  fractures.  The  excellent,  though 
nearly  obsolete,  practice  of  laying  on  such  wounds  a  pad  of  lint  soaked 
in  the  blood,  was  a  good  imitation  of  the  most  natural  process  of  their 
repair. 

If  a  blood-scab  be  not  formed  over  a  wound,  or  if  such  a  one  have 
been  detached  after  being  formed,  then  at  once  a  scab  may  be  derived 
from  the  serum  and  lymph  that  ooze  from  the  surface  of  the  wound. 
Thus  it  is  commonly  with  wounds  in  animals  that  are  left  to  themselves, 
and  in  many  small  wide-open  wounds  in  our  own  case.  Thus,  also,  I 
imagine,  the  best  healing  of  superficial  burns  and  scalds  is  effected, 
when  the  exposed  surface  is  covered  with  cotton-wool  or  other  sub- 
stance, which,  as  the  oozing  fluids  become  entangled  with  it,  may  help 
them  to  form  a  scab. 

At  a  yet  later  period,  the  pus  produced  from  exposed  granulating 
wounds  may  concrete  on  them,  and  they  will  heal  under  it  excluded 
from  the  air.  Such  a  process  may  also  ensue  in  the  healing  of  ulcers, 
and  has  been  successfully  imitated  in  Mr.  Stafford's  plan  of  filling  deep 
ulcers  with  wax. I  In  any  case,  the  healing  process  is  probably  just 
the  same  as  that  under  scabs  of  blood  or  serum;  but  I  believe  it  has 
not  yet  been  exactly  determined  what  are  the  changes  that  ensue  in  the 
surface  beneath  the  scab.  So  far  as  one  can  discern  with  the  naked 
eye,  the  wounded  surface  forms  only  a  thin  layer  of  cuticle  on  itself ; 
no  granulations,  no  new  connective  tissue,  appear  to  be  formed ;  the 
raw  surface  merely  skins  over,  and  it  seems  to  do  so  uniformly,  not  by 
the  progressive  formation  of  cuticle  from  the  circumference  towards  the 
centre,  as  is  usual  in  open  wounds. 

The  healing  of  a  wound  by  scabbing  has  always  been  thought  a 
desirable  process ;  and  when  one  sees  how  quickly,  by  means  of  this 
process,  wounds  in  animals  are  healed,  and  with  how  little  general  dis- 
turbance, one  may  well  wish  that  it  could  be  systematically  adopted. 
But  to  this  there  seems  some  hindrance.     Many  surgeons  have  felt,  as 

*  In  his  Lecture  on  Surgery,  in  the  Lancet  for  1S32-3,  vol.  ii. 

f  Mr.  Henry  Lee  tells  me  that  a  similar  case  has  occurred  in  his  practice.  An  excellent 
instance  of  healing  under  blood-scabs  is  also  related  by  Dr.  Macartney  (Treatise  on  Inflam- 
mation, p.  208). 

J  On  the  Treatment  of  the  Deep  and  Excavated  Ulcer.     1829. 


168  SUPPURATION. 

Mr.  Hunter  did,  that  the  scabbing  process  should  be  permitted  much 
oftener  than  it  is,  in  the  cases  of  both  wounds  and  ulcers ;  but  none 
have  been  able  to  lay  down  sufficient  rules  for  the  choice  of  the  cases  in 
which  to  permit  it.  Probably,  the  reason  of  this  is  that,  at  the  best, 
in  the  human  subject,  the  healing  by  scabbing  is  an  uncertain  process. 
When  the  scab  is  once  formed,  and  the  wound  covered  in,  it  is  neces- 
sary that  no  morbid  exudation  should  take  place.  Whenever,  there- 
fore, inflammation  ensues  in  a  wound  or  sore  covered  with  a  scab,  the 
exuded  fluid,  collecting  under  the  scab,  produces  pain,  compresses  the 
wounded  surface,  or  forces  off  the  scab,  with  discomfort  to  the  patient 
and  retardation  of  the  healing.  I  suspect  that  the  many  instances  of 
disappointment  from  this  cause  have  led  to  the  general  neglect  of  the 
process  of  scabbing  in  the  treatment  of  wounds.  The  observance  of 
perfect  rest,  and  of  the  other  means  for  warding  off  inflammation,  will, 
however,  make  it  a  valuable  auxiliary  in  the  treatment  of  wounds, 
especially  of  large  superficial  ones  :  in  the  treatment  of  small  wounds, 
collodion  appears  sufficient  to  accomplish  all  that  scabbing  would  do : 
and  in  deep  wounds,  fluid  is  too  apt  to  collect  under  the  scab. 

Such  are  the  several  methods  of  healing  observed  after  wounds  of 
soft  parts;*  and  in  connection  with  them,  two  subjects  remain  to  be 
considered,  namely,  the  process  of  suppuration,  and  that  of  the  perfect- 
ing of  scars. 

Respecting  the  process  of  suppuration,  it  cannot  be  necessary  that  I 
should  give  a  minute  account  of  pus  or  of  its  general  or  chemical  cha- 
racters :  I  will  rather  endeavor  to  show  its  relations  to  the  healing  pro- 
cess, by  illustrating  the  points  of  resemblance  and  of  difference  between 
it  and  the  materials  of  which  granulations  are  formed. 

Let  me  remind  you  that  the  formation  of  granulations  is  not  neces- 
sarily attended  with  the  production  of  pus.  I  have  already  referred  to 
this  fact  in  speaking  of  the  formation  of  subcutaneous  granulations, 
such  as  are  sometimes  seen  on  the  end  of  bones  that  do  not  unite,  in  the 
ordinary  way,  after  simple  fractures.  Mr.  Hunter  also  expressly 
describes  these  cases ;  and  the  same  kind  of  granulations  without  sup- 
puration may  be  sometimes  seen  springing  from  the  ulcerated  articular 
surfaces  of  bones,  in  cases  of  diseased  joint  without  any  external 
opening. f 

■^  I  have  not  been  able  to  recognize  what  Dr.  Macartney  named  the  modelling  process  as 
a  method  of  healing  distinct  from  that  which  ensues  in  the  most  favorable  instances  of 
healing  by  granulations.  I  have,  therefore,  not  enumerated  it  among  the  modes  of  healing; 
yet  it  may  occur  in  some  conditions  that  I  have  not  met  with  :  I  would  not  wish  to  impute 
confusion  to  so  good  and  independent  an  observer  as  Dr.  Macartney. 

■}■  Dr.  Redfern,  from  his  researches  into  the  changes  taking  place  in  ulceration  of  the  ar- 
ticular cartilages,  was  of  opinion  that  pus  had  never  been  shown  to  be  formed  from  the, 
substance  of  the  diseased  cartilage.  But  the  more  recent  observations  of  C.  0.  Weber] 
(Virchow's  Archiv,  B,  xiii,  1858),  with  whom  Barwell  also  coincides  (Treatise  on  Diseases j 
of  Joints),  tend  to  the  conclusion  that  pus  in  these  cases  may  be  derived  from  a  multiplica- 
tion of  the  nuclei  of  the  cartilage  corpuscles. 


SUPPURATION. 


169 


However,  when  granulations  are  formed  on  an  open  wound,  there  is 
always  suppuration;  i.  e.,  an  opaque,  creamy,  yellowish-white  or  green- 
ish-white fluid,  pus,  or  matter,  is  produced  on  the  surface  of  the  granu- 
lations. If  the  surface  be  allowed  to  dry,  the  pus  may  form  a  scab  :  if 
it  be  kept  moist,  fresh  quantities  of  pus  are  produced,  till  the  surface 
of  the  granulations  is  covered  with  the  new  cuticle.  Granulations  that 
are  skinned  over  no  longer  suppurate. 

The  essential  constituents  of  pus  are  cells,  and  the  liquid  (liquor 
puris)  in  which  they  are  suspended.  In  pus  produced  during  healthy 
granulation,  no  other  material  than  these  may  be  found.  But,  often, 
minute  clear  particles,  not  more  than  jo^oo  ^^  ^^  i^^^  i^  diameter,  are 
mingled  with  the  pus-cells.  And,  when  the  process  deviates  from  health, 
we  find  not  only  variations  in  the  pus-cells,  but  multiform  mixtures  of 
withered  cells,  molecular  and  fatty  matter,  free  or  escaped  and  shrivel- 
led nuclei,  blood-corpuscles,  fragments  of  granular  substance  like  shreds 
of  fibrine,  and  other  materials.  All  these  indicate  defects  or  disease  of 
pus,  corresponding  with  those  of  the  granulations  to  which  I  have  al- 
ready referred. 

Pus-cells,  in  their  ordinary  state,  are  represented  in  the  adjoining 
sketch. 

¥is:.  20. 


As  shown  at  A,  they  are  spherical  or  spheroidal,  or  even  discoid  bo- 
dies; the  differences  in  shape  depending  apparently  on  the  density  of 
the  fluid  suspending  them.  In  the  same  proportion  as  it  becomes  less 
dense,  they  tend  to  assume  the  more  perfectly  spherical  shape.  They 
have  a  uniform  nebulous  or  grumous  aspect ;  distinct  granules,  more 
or  less  numerous,  are  commonly  seen  in  them  ;  and  they  appear  more 
darkly  nebulous  and  more  granular  in  the  same  proportion  as  the  fluid 
becomes  more  dense.  Their  usual  diameter  is  from  ^sVo  ^^  sooo  ^^  ^^ 
inch.  Sometimes  a  distinct,  circular,  dark-edged  nucleus  may  be  seen 
in  the  paler  corpuscles ;  and,  more  rarely,  two  or  even  three  particles 
like  a  divided  nucleus. 

When,  as  in  the  corpuscles  B,  water  is  added  to  pus,  it  usually  pene- 
trates the  cells,  expanding  them,  raising  up  a  distinct  fine  cell-wall, 
and  separating  or  diffusing  their  contents.  Sometimes  the  contents  are 
uniformly  dispersed  through  the  distended  cell,  which  thus  becomes 
more  lightly  nebulous,  or  appears  filled  with  a  nearly  clear  substance 
in  which  the  minute  particles  vibrate  with  molecular  movement,  while 
in  or  near  the  centre  a  dark- edged  well-defined  nucleus  may  appear. 

12 


170  SUPPURATION. 

Sometimes,  while  the  cell-wall  is  upraised,  the  whole  contents  of  the 
cell  subside  into  a  single  ill-defined  darkly  nebulous  mass,  which  re- 
mains attached  to  part  of  the  cell-wall,  looking  like  a  nucleus,  but  dif- 
fering from  a  true  nucleus  in  the  characters  just  assigned,  as  well  as  in 
the  absence  of  the  two  or  three  shining  particles  like  nucleoli.  Lastly, 
a  few  pus-corpuscles  appear  unchanged  by  the  action  of  water :  they 
seem  to  be  merely  masses  of  soft  colorless  substance,  having  the  shape 
and  appearance,  but  not  the  structure,  of  cells. 

When  dilute  acetic  acid  is  added  to  pus  (as  in  Fig.  c),  it  produces  the 
same  effects  as  water,  but  more  quickly,  and  with  a  more  constant  ap- 
pearance of  two,  three,  or  four  small  bodies  like  nuclei.  These  bodies 
are  remarkable,  though  far  from  characteristic,  features  of  pus-cells. 
They  are  darkly  edged,  usually  flattened,  clear,  and  grouped,  as  if 
formed  by  the  division  of  a  single  nucleus  :  and  commonly  each  of  them 
appears  darkly  shaded  at  its  centre.  When  the  acetic  acid  has  been 
too  little  diluted,  these  bodies  alone  may  be  at  first  seen  :  for  the  cell- 
wall  and  the  rest  of  its  contents  may  be  rendered  so  transparent  as  to 
be  scarcely  visible. 

Such  are  the  pus-cells  found  in  healthy  suppurating  wounds.  The 
liquor  puris  contains  albumen,  a  compound  called  pyin,  regarded  by 
Mulder  as  identical  with  tritoxide  of  protein,  occasionally  chondrin, 
glutin  and  leucine,  abundant  fatty  matter,  and  inorganic  substances 
similar  to  those  dissolved  in  the  liquor  sanguinis. 

Pus  not  distinguishable  from  that  of  granulating  wounds  is  formed  in 
many  other  conditions ;  as  in  inflamed  serous  and  mucous  cavities,  and 
in  abscesses.  In  these  relations  it  will  be  considered  in  the  lectures  on 
Inflammation.  But  the  histories  of  all  cases  of  the  formation  of  pus 
concur,  with  that  of  suppurating  wounds,  to  the  conclusion  that  pus 
may  be  regarded  as  a  rudimental  substance  ill-developed  or  degenerated  ; 
as  a  substance  essentially  similar  to  the  materials  of  granulations,  or 
of  the  lymph  of  inflammatory  exudation,  but  which  fails  of  being  de- 
veloped like  them,  or,  after  having  been  developed  like  them,  to  a  cer- 
tain stage,  degenerates. 

To  illustrate  this  relation  between  the  pus  and  the  granulations  of 
healing  wounds,  I  may  state  that  the  last  figure  was  copied  from  sketches 
that  I  made,  at  the  same  time,  of  some  granulation-cells  from  the  walls 
of  a  sinus,  and  some  pus-cells  from  a  healthily  granulating  wound.     I 
chose  those  sources  purposely,  that  I  might  be  able  to  compare  ill-de- 
veloped granulation- cells  with  well-constructed  pus-cells ;  and  a  com^ 
parison  of  them  showed  that,  whether  as  seen  without  addition,  or  a^ 
changed  by  the   action  of  water  and   acetic  acid,  they  were  not  to  b( 
distinguished  from  one  another.     Had  I  not  seen  the  vessels  in  the  tis-^ 
sue  that  the  granulation-cells  formed,  I  might,  in  the  first  examination,! 
have  almost  thought  I  was  deceived  in  thinking  they  were  not  pus-cells.j 
The  six  varieties  of  the  appearances  of  the  cells  which  are  represented,! 
might  have  been  taken  from  either  source ;  so  might  some  other  varie- 


SUPPURATION.  171 

ties  :  but  these  may  suffice  to  show  the  apparent  identity  of  structure 
between  well-formed  pus-cells  and  ill-developed  or  degenerate  granula- 
tion-cells, such  as  are  found  in  the  walls  of  sinuses  and  the  like  half- 
morbid  structures.  I  do  not  mean  to  say,  generally,  that  granulation-cells 
and  pus-cells  cannot  be  distinguished  ;  for  between  well-formed  granu- 
lation-cells, such  as  are  found  in  healing  wounds,  and  any  particles  that 
are  usually  found  in  pus,  certain  distinctions  are  almost  always  manifest. 
The  pus-cells  are  darker,  more  and  more  darkly  granular,  more  various 
in  size,  and  more  various,  not  in  shape,  but  in  apparent  structure,  more 
often  containing  numerous  particles,  like  fatty  molecules,  more  rarely 
showing  a  nucleus  when  neither  water  nor  acetic  acid  is  added,  and  much 
more  commonly  showing  a  tripartite  or  ill-formed  nucleus  under  the 
action  of  the  acid.  None,  however,  of  these  characters  is  indicative  of 
essential  difference ;  and  between  even  the  widest  extremes  there  are  all 
possible  gradations,  till  distinction  is  impossible  ;  so  that  when  you 
place,  as  I  have  often  done,  ill-developed  or  degenerate  granulation-cells 
on  one  side  of  the  microscope-field,  and  pus-cells  on  the  other,  there  is 
not  a  form  of  corpuscle  on  the  one  which  is  not  repeated  on  the  other. 

From  this,  one  cannot  but  conclude  that  the  cells  of  pus  from  wounds 
are  ill-developed  or  degenerate  granulation-cells.  Some  of  them  may  be 
degenerate,  i.  e.,  they  may  have  been,  as  granulation-cells,  attached 
for  a  time  to  the  surface  of  the  granulation-layer,  and  having  lived  their 
time,  may,  in  ordinary  course,  have  been  detached  and  shed,  as  epithe- 
lial cells  are  from  healthy  surfaces.  They  may  be  thus  detached  after 
more  or  less  degeneration,  and  hence  may  result  some  of  the  modifica- 
tions that  they  present.  But  some  pus-cells,  I  imagine  (at  least  in  the 
healing  of  wounds),  may  be  ill-developed ;  that  is,  imperfectly  formed 
of  the  granulation  material,  which,  being  exposed  to  the  air,  or  being 
too  remote  from  the  supply  of  blood,  cannot  attain  its  due  development, 
and,  in  an  imperfectly  developed  state,  is  soon  cast  off. 

The  many  characters  of  imperfection  or  of  degeneracy  that  pus-cells 
show,  accord  with  this  view :  such  as  the  general  imperfection  of  their 
nuclei ;  the  frequent  abundance  of  fatty-looking  granules  in  them ;  the 
large  quantity  of  fatty  matter  that  analysis  detects  in  pus ;  and  the 
limitation  of  the  cells  to  certain  forms,  beyond  which  they  are  never 
found  developed,  though  none  of  these  forms  is  more  highly  organized 
than  that  of  the  youngest  or  most  rudimental  granulation-cell.* 

A  further  confirmation  of  the  opinion  that  pus-cells  are  ill-developed 
or  degenerate  granulation-cells,  is  furnished  in  the  cases,  to  which  I 
shall  hereafter  refer,  in  which  pus-cells  are  produced  after,  or  together 
with,  inflammatory  lymph-cells ;  as  in  abscesses,  inflamed  membranes, 
and  the  like.  Now  such  lymph-cells  are  not  distinguishable  in  apparent 
structure  from  granulation-cells,  and,  like  these,  they  may  show  every 
gradation  of  form  to  that  of  the  pus-cell. 

*  In  a  note  to  Lecture  XVI,  a  description  of  the  views  held  by  many  pathologists  of  the 
formation  of  pus  by  the  proliferation  of  the  nuclei  of  the  textures  is  given. 


172  SUPPURxiTION. 

But  it  is  not  only  in  the  cells  that  we  may  trace  this  appearance  of 
the  degeneracy  or  incomplete  development  of  pus.  It  is  equally  shown 
in  the  fluid  part,  or  liquor  puris,  which,  unlike  the  intercellular  sub- 
stance of  granulations  and  inflammatory  lymph,  is  incapable  of  organi- 
zation, even  when,  by  evaporation  or  partial  absorption,  it  assumes  the 
solid  form.  The  liquor  puris  answers,  in  its  relations  to  the  cells,  to 
the  solid  and  organizable  intercellular  substance  of  granulations  ;  and 
as  undue  liquidity  is  among  the  most  decided  marks  of  ill-formed  pus, 
so  the  abundance  of  the  blastema,  in  proportion  to  the  cells,  is  one  of 
the  best  signs  that  granulations  are  caj^able  of  quick  development. 

These  considerations  may  suggest,  in  some  cases,  the  imperfection  of 
the  liquor  puris ;  and  an  observation,  which  any  one  may  easily  make, 
seems  to  indicate  that  it  may,  in  other  cases,  be  the  product  of  the 
degeneration  and  liquefaction  of  the  solid  blastema,  as  the  pus-cells  are, 
in  the  same  cases,  of  the  granulation  or  inflammatory  lymph-cells  im- 
bedded in  it.  If  the  formation  of  abscesses  be  watched,  one  may  see, 
on  one  day,  a  large  solid  and  inflamed  swelling,  firm  and  almost  un- 
yielding, giving  no  indication  of  containing  any  collection  of  fluid;  but, 
next  day,  one  may  detect  in  the  same  swelling  the  signs  of  suppura- 
tion ;  the  border  may  feel  as  firm  as  before  ;  but  all  the  centre  and  the 
surface  may  be  occupied  with  an  ounce  or  more  of  matter.  And  ob- 
serve, this  change  from  the  solid  to  the  liquid  state  may  have  ensued 
without  any  increase  of  the  swelling.  Such  an  increase  must  have 
occurred  had  the  pus  been  secreted  in  a  fluid  state  into  the  centre  of 
the  solid  mass  :  and  the  changes  cannot,  I  think,  be  explained  except 
on  the  admission,  that  the  inflammatory  product,  which  was  eff"used  and 
infiltrated  through  the  tissue  in  a  solid  form,  has  been  liquefied :  its 
cells  degenerating  into  pus-cells,  its  blastema  into  liquor  puris.* 

Can  we  assign  any  use  or  purpose  to  the  process  of  suppuration  ?  In 
the  case  of  abscesses  and  acute  inflammations  we  may  discern  no  more 
of  purpose  than  in  any  other  disease.  But  in  the  case  of  granulating 
wounds,  the  use  commonly  assigned  to  pus,  that  it  serves  as  a  protection 
to  the  granulations,  is  probably  ascribed  to  it  with  reason.  It  does 
this  even  in  the  fluid  state  ;  but  the  devices  of  surgical  treatment, 
having  regard  to  present  comfort,  rarely  let  us  see  how  much  better  it 
protects  a  wounded  surface  when,  as  in  animals,  it  is  allowed  to  dry 
into  a  scab. 

Let  us  now  consider  the  case  of  a  wound  completely  healed,  and  the! 
scar  that  occupies  its  place. 

It  is  hard  to  describe  in  general  terms  the  characters  of  scars,  vary- 

*  Such  a  liquefaction  is  not  that  assumed  in  the  older  doctrines,  which  held  that  pus  wasJ 
partly  formed  of  the  dissolved  materials  of  the  original  tissues.     The  original  tissues  doubtJ 
less  remain,  unless  partially  absorbed :  yet  there  appears  to  be  thus  much  of  liquefaction  inj 
the  formation  of  an  abscess,  that  part  of  the  inflammatory  product,  first  formed  as  a  sof 
solid,  degenerates  and  becomes  fluid. 


SCABS.  173 

ing  as  they  do  in  accordance  with  the  peculiar  positions,  and  forms,  and 
modes  of  healing  of  wounds.  But  two  things  may  be  constantly  ob- 
served in  them :  namely,  their  contraction,  and  the  gradual  perfecting 
of  their  tissues. 

A  process  of  contraction  is  always  associated  with  the  development 
of  granulations.  Mr.  Hunter  has  minutely  described  it,  and  preserved 
several  specimens  to  illustrate  it :  among  which  are  two  stumps,*  in 
which  its  occurrence  is  proved  by  the  small  size  of  the  scars  in  com- 
parison with  that  of  the  granulating  surfaces  which  existed  before  them. 
This  healing  of  stumps,  especially  after  circular  amputations,  will 
always  show  the  contraction  of  the  granulations,  even  before  the  cica- 
trix is  formed ;  for  one  sees  the  healthy  skin  drawn  in  and  puckered 
over  the  end  of  the  stump,  before  any  cuticle  is  formed  on  the  granula- 
tions, except  perhaps  on  the  very  margin.  And  many  injuries,  but 
especially  burns,  show  the  contraction  of  the  scar  continuing  long  after 
the  apparent  healing  is  completed. 

To  what  may  we  ascribe  this  contraction  of  both  the  granulations 
and  the  scar  ?  It  has  been  regarded  as  the  result  of  some  vital  power 
of  contraction  ;  and  possibly  it  may  be  so  in  some  measure.  Yet,  on 
the  whole,  it  seems  rather  to  be  the  necessary  mechanical  effect  of  the 
changes  of  form  and  construction  that  the  parts  undergo.  The  same 
change  ensues  in  the  organization  of  inflammatory  products :  as,  e.  g.^ 
in  false  membranes,  indurations,  thickenings  of  parts,  and  the  like  con- 
sequences of  the  exudation  and  organization  of  lymph. 

Now,  in  all  these  cases,  the  form  of  the  cell,  while  elongating  into  a 
fusiform  body,  is  so  changed  that  it  will  occupy  less  space.  The  whole 
mass  of  the  developing  cells  becomes  more  closely  packed,  and  the  tis- 
sue that  they  form  becomes  much  drier  ;  with  this,  also,  there  is  much 
diminution  of  vascularity.  Thus,  there  results  a  considerable  decrease 
of  bulk  in  the  new  tissue  as  it  develops  itself ;  and  this  decrease,  be- 
ginning with  the  development  of  the  granulation-cells,  continues  in  the 
scar,  and,  I  think,  sufficiently  accounts  for  the  contraction  of  both, 
without  referring  to  any  vital  power. 

The  force  with  which  the  contraction  is  accomplished  is  often  enor- 
mous. One  sees  its  result  in  the  horrible  deformities  that  follow  the 
healing  of  severe  burns.  Deep  scarred  and  seamed  depressions,  even 
of  the  bones,  may  be  produced  by  the  contraction  of  granulations  and 
scars  over  them.  The  whole  process  shows  the  error  of  such  expres- 
sions as  "  filling  up  with  granulations,"  commonly  applied  to  deep 
healing  wounds,  as  if  granulations  increased  in  thickness  till  they  at- 
tained the  level  of  the  upper  margins  of  deep  hollows.  The  truth  is, 
that,  even  in  the  deepest  open  wounds,  the  granulation-layer  is,  as 
usual,  from  one  to  three  lines  thick;  and  that,  when  such  a  wound 
grows  shallower  in  healing,  it  is  not  by  the  rising  of  the  granulations, 

*  Nos.  28  and  29  in  the  Museum  of  the  CoUese. 


174  SCABS. 

but  by  the  lowering  of  its  margins.     The  granulations  and  the  scars  of 
deep  open  wounds  remain  alike  thin  and  depressed. 

The  improvement  and  perfecting  of  the  tissue  of  the  scar  is,  again,  a 
very  slow  process.  It  is  often  thought  remarkable  that  nerves  and 
some  of  the  higher  tissues  should  require  so  long  time  for  their  repair ; 
but  scarcely  less  is  necessary  for  the  perfecting  of  a  common  scar.  The 
principal  changes  by  which  it  is  accomplished  include  the  removal  of 
all  the  rudimental  textures,  the  formation  of  elastic,  tissue,  the  improve- 
ment of  the  fibrous  or  fibro-celliilar  tissue,  and  of  the  new  cuticle,  till 
they  are  almost  exactly  like  those  of  natural  formation;  and  the  gradual 
loosening  of  the  scar,  so  that  it  may  move  easily  on  the  adjacent  parts. 
The  scar  also  becomes  paler  and  more  shining  than  the  surrounding 
unaffected  skin,  for  the  numerous  vessels,  which  the  granulating  surface 
possessed,  gradually  disappear,  and  are,  for  the  most  part,  converted 
into  fibrous  cords. 

All  these  changes  are  very  slowly  accomplished.  One  sees  their 
effects,  it  may  be,  only  after  the  many  years  in  which,  as  it  is  said,  the 
scars  of  childhood  gradually  wear  out;  i.  e.,  in  which  the  new-formed 
tissues  gradually  acquire  the  exact  similitude  of  the  old  ones.  Thus, 
the  remains  of  the  rudimental  connective  tissue,  imperfectly  developed, 
may  be  found  in  apparently  healthy  scars  of  ten  months'  duration. 
After  second  operations,  in  which  the  scar  of  some  former  wound  was 
removed,  I  have  still  found  imperfectly  developed  granulation- cells  in 
the  tissue  of  the  scar.  Elastic  tissue,  also,  I  think,  is  not  commonly 
formed  in  the  first  construction  of  a  scar,  but  appears  in  it  sometimes 
as  rhiich  as  twelve  months  after  its  first  formation,  and  then  gives  it  the 
common  structure  of  the  mixed  white  fibrous  and  elastic  tissues  which 
exist  in  the  cutis. 

But,  an'  occurrence  which  may  appear  more  singular  than  this  slow 
perfecting  of  the  tissues,  is,  in  all  good  scars,  as  they  are  called,  that 
gradual  loosening  of  the  tissue  which  at  first  unites  the  scar  to  all  the 
adjacent  parts.     Thus,  in  such  a  wound  as  is  made  for  tying  a  deep  ar- 
tery, or  in  lithotomy,"  at  first  the  new  tissue,  the  tissue  of  the  scar,  ex- 
tends down  to  the  bottom  of  the  wound,  equally  dense  in  all  parts,  and 
fastening  the  skin  to  the  parts  at  the  very  deepest  portion  of  the  wound. 
But  after  a  time  this  clears  up.     The  tissue  of  the  scar  in  the  skin  be- 
comes more  compact  and  more  elastic  ;  but  that  beneath  it  becomeSj 
looser  and  more  like  natural  connective  tissue,  and  the  morbid  adhe- 
sions of  one  part  to  another  are  freed.     So,  after  injuries  or  diseases,! 
followed  by  scars  about  joints,  the  stiffness  depending  on  the  adhesion^ 
of  the  scar  to  the  deeper  tissues  gradually  decreases :   and   so,  in  like 
manner,  the  scars  of  burns  often  become  gradually  and  of  themselves  i 
more  pliant,  and  the  parts  which  they  held  become  more  freely  mova- 
ble, though  sometimes  scarcely  seeming  to  change  for  a  year  after  the  j 
first  healing  of  the  injury. 


REPAIR     OF    FRACTURES.  175 

Now,  in  all  this  gradual  return  of  tissues  to  the  healthy  state,  we 
may  trace,  I  think,  a  visible  illustration  of  the  recovery  from  the  minute 
changes  of  disease.  In  all  there  is  a  gradual  approach  of  the  new  par- 
ticles that  are  successively  produced,  to  a  nearer  conformity  with  the 
specific  character  of  the  parts  they  should  replace,  till  repair  becomes 
almost  reproduction.  And  how,  let  me  ask,  can  all  this  be  reconciled 
with  any  theory  of  assimilation  ?  How  can  assimilation  alter  the  cha- 
racters of  a  scar  ?  How  make  one  part  of  it  assume  one  character,  and 
another  part  a  character  quite  diiferent,  till,  at  length,  that  which 
looked  homogeneous,  as  a  mass  of  new-formed  tissue,  acquires,  in  sepa- 
rate parts,  the  characters  of  the  several  tissues  in  whose  place  it  lies, 
and  whose  ofiice  it  is  destined,  though  still  defectively,  to  discharge  ? 


LECTURE  XI. 

THE    REPAIR    OF   FRACTURES. 

The  necessity,  which  I  have  felt  in  the  preceding  lectures,  of  describ- 
ing the  healing  process  as  it  is  observed  in  a  few  typical  examples,  is 
increased,  when  I  come  to  the  consideration  of  the  repair  of  fractures. 
A  volume  would  not  suffice  for  all  that  should  be  said  of  it ;  for  there 
are  no  examples  of  the  reparative  process  which  present  so  many  fea- 
tures of  interest  as  this  does,  whether  we  consider  its  practical  impor- 
tance, or  the  wide  field  which  it  ofiers  alike  for  the  science  and  for  the 
art  of  surgery,  or  the  abundant  illustrations  of  the  general  principles  of 
recovery  from  injury  which  are  present  in  every  stage  of  the  process, 
or  the  perfect  evidences  of  design  which  it  displays,  of  design  that 
seems  unlimited  in  the  variety  and  point  with  which  it  is  adapted  to  all 
the  possible  diversities  of  accident.  To  consider  the  repair  of  fractures 
completely,  in  any  of  these  views,  would  be  far  beyond  my  purpose,  and 
farther  beyond  my  ability.  I  shall  therefore  limit  myself  almost  en- 
tirely to  an  account  of  the  repair  of  the  simple  fractures  of  long  bones. 
What  is  true  of  this  will  be  so  nearly  true  of  the  repairs  of  other  frac- 
tures, that  a  few  words  may  suffice  in  reference  to  the  chief  modifications 
of  the  process  in  them.  Moreover,  I  shall  in  general  describe  only  what 
occurs  in  the  adult  human  subject. 

The  injury  inflicted  in  the  fracture  of  a  long  bone  is  rarely  limited  to 
the  bone.  The  two  or  more  fragments,  driven  in  opposite  directions, 
penetrate  the  adjacent  tissues,  wounding  and  bruising  them,  and  giving 
rise  to  bleeding  of  various  amount.  Provided  all  these  injuries  are 
subcutaneous,  and  the  air  has  no  access  to  the  damaged  parts,  their  re- 
pair is  perfectly,  though  slowly,  eff"ected.  It  is  not  unfrequent,  in 
recent  fractures,  to  find  portions  of  muscle  or  other  soft  parts  com- 


176  EEPAIR    OF    FRACTURES. 

pletely  crushed  by  the  bones,  or  even,  in  minute  fragments,  inclosed 
in  the  reparative  material  or  the  inflammatory  exudations ;  and  yet, 
■when  similar  fractures  are  examined  a  year  or  more  after  their  occur- 
rence, the  tissues  round  the  bone  appear  quite  normal  in  their  struc- 
ture, however  disturbed  they  may  be  in  their  relations. 

The  periosteum  is  rarely  much  damaged  in  fractures  of  long  bones,  h 
It  is  seldom  stripped  off  the  broken  ends.  Commonly,  it  is  cleanly  " 
rent  across  at  the  same  level  as  the  bone  is  broken,  and  maintains  its 
close  union,  having  only  its  fibres  somewhat  frayed  or  pulled  from  their 
natural  direction.  Sometimes,  indeed,  it  remains  entire,  even  in  exten- 
sive fractures  ;  and  in  this  case,  thickening,  it  contributes  to  the  security 
of  the  repair  of  the  injury. 

The  extravasation  of  blood  about  fractures  is  not  only  uncertain  in 
amount,  but  unequal  in  the  several  tissues.  Its  abundance  in  the  sub- 
cutaneous tissue  is  often  so  remarkable,  as  to  be  among  the  useful  signs 
for  diagnosis,  in  cases  of  doubtful  fracture  near  joints ;  but  in  the 
deeper  soft  tissues  less  blood  is  shed  ;  and,  commonly,  in  the  periosteum, 
near  the  broken  ends  of  the  bone,  only  a  few  spots  of  blood  are  seen. 
I  have  already  spoken  (p.  137)  of  the  manner  in  which  the  extravasated 
blood  is  disposed  of;  and  since  it  rarely  appears  to  take  part  in  tne 
reparative  process,  I  shall  make  no  further  mention  of  it. 

Some  days  elapse,  after  a  fracture,  before  any  clear  marks  of  a  re- 
parative process  can  be  found.  An  early  consequence  of  the  injury 
appears  to  be  the  exudation  of  a  small  quantity  of  inflammatory  lymph ; 
so  that  the  nbro-cellular  tissue  in  and  near  the  seat  of  injury  appears 
more  succulent  than  is  natural,  being  infiltrated  with  a  serous-looking 
fluid,  in  which  are  cells  like  those  of  granulations  or  lymph. 

In  bad  cases,  this  exudation  may  increase,  and  add  to  the  swelling 
that  is  often  seen  to  augment  in  the  second  or  some  later  day ;  but,  in 
better  instances  of  repair,  and  when  the  parts,  even  though  much  in- 
jured, are  kept  at  rest,  I  think  the  inflammatory  exudation  usually 
ceases  after  the  second  or  third  day,  and  that,  then,  some  days  pass  before 
the  proper  reparative  material  is  produced.*  The  state  of  the  injured 
parts  during  this  period  of  calm,  or  of  incubation,  is  probably  like  that 
observed  in  wounds  of  soft  parts  (p.  152).  Its  duration  is  uncertain, 
but,  I  think,  in  the  adult,  is  rarely  less  than  one  week  or  more  than  two. 

In  this  long  period  of  inaction  we  find  the  first  contrast  between  the 
repairs  of  fractures  in  man,  and  in  the  animals  that  have  been  used  for 
experimental  inquiry  into  the  process,  as  dogs,  rabbits,  pigeons,  and 
others.  In  any  of  these,  an  abundant  reparative  material  will  be  pro- 
duced, and  organized  into  cartilage  or  bone,  in  a  time  little  longer  than 
elapses  before  the  first  commencement  of  the  process  in  a  man.f     We 

*  More  concerning  this  inflammatory  exudation  will  be  related  in  the  account  of  the  re- 
pair of  tendons,  in  the  next  lecture. 

t  See  Nos.  418,  419,  420,  in  the  Museum  of  the  College ;  and  Series  iii,  Nos.  69,  70,  71 ,  &c., 
in  that  of  St.  Bartholomew's. 


REPAIR    OF    FRACTURES.  177 

cannot,  therefore,  from  the  rapidity  of  repair  in  any  lower  animals,  form 
any  just  calculation  of  its  rate  of  progress  in  ourselves. 

The  proper  reparative  process,  commencing  after  this  period  of  rest, 
may  usually  be  divided  into  two  chief  parts;  namely,  the  process  of 
uniting  the  fragments,  and  that  of  shaping  or  modelling  them  and  their 
combining  substance.  The  uniting  and  the  modelling  parts  of  the  process 
are  so  dijBTerent  in  nature  and  in  time,  that  they  may  well  be  considered 
separately.  They  are  comparable  with  the  forming  and  the  subsequent 
perfecting  of  the  scars  of  wounded  soft  parts  ;  and  in  the  union  of  frac- 
tures, even  more  evidently  than  in  any  other  instance  of  repair,  we  may 
note  how  safety  is  first  provided  for,  then  symmetry;  how  the  welfare 
of  the  individual  is  first  secured,  and  then  the  conformity  of  the  repaired 
part  to  the  typical  or  specific  form ;  for  the  modelling  scarcely  begins 
before  the  uniting  is  completed. 

The  union  of  fractures  is  commonly  effected  by  the  organization  of 
new  material  connecting  the  fragments.  Sometimes,  indeed,  immediate 
union  occurs.  When  portions  of  bone  are  placed  and  held  in  exact 
apposition,  they  may  be  united  without  any  new  material  being  formed 
for  their  connection ;  a  continuity  of  tissues  and  of  bloodvessels  being 
restored,  as  in  the  cases  of  healing  by  immediate  union  of  soft  parts. 
But  this  is  rare,  and  has  not  yet  been  sufficiently  studied. 

The  material  deposited  for  the  more  usual  method  of  repair  of  simple 
fractures, — the  callus,  as  it  is  called,  when  it  has  become  firm  or  hard, — 
is,  I  think,  in  the  first  instance,  not  visibly  diff"erent  from  the  material 
formed  for  the  repair  of  other  subcutaneous  injuries.  Its  peculiarity  is 
shown  in  the  direction  and  end  of  its  development ;  and,  in  this  respect, 
the  repair  of  fractures  supplies  an  extreme  case  of  the  variety  of  ways 
through  which  the  same  end  of  development  may  be  attained. 

In  its  first  production,  the  reparative  material  is  a  structureless  or 
dimly  shaded,  or  granular  substance,  like  fibrine ;  or,  perhaps  at  a  later 
period,  it  is  ruddy,  elastic,  moderately  firm  and  succulent,  like  firm 
granulation-substance.  Of  the  manner  in  which  it  is  placed,  in  the 
space  and  in  the  tissues  around  or  between  the  fragments  to  be  connected, 
I  will  speak  presently.  At  first,  it  has  none  of  the  firmness  belonging 
to  the  "callus:"  this,  however,  it  soon  attains,  as  it  makes  progress 
towards  being  transformed  into  bone.  Its  ossification,  as  I  have  said, 
may  be  accomplished  through  several  transitional  forms  of  tissue,  which 
might  be  distinguished  as  so  many  varieties  of  callus,  if  the  term  be 
worth  retaining.  It  may  become,  before  ossifying,  either  fibrous  or 
cartilaginous,  or  may  assume  a  structure  intermediate  between  these  ; 
and,  in  either  of  these  cases,  ossification  may  ensue  when  the  previous 
tissue  is  yet  in  a  rudimental  state,  or  may  be  delayed  till  the  complete 
fibrous  or  cartilaginous  structure  is  first  achieved. 

I  cannot  tell  the  conditions  which  will  determine,  in  each  case,  the 
route  of  development  towards  bone  that  the  reparative  material  will 
take ;  nor  in  what  measure  the  differences  that  may  be  observed  are  to 


178  KEPAIR    OF    FRACTURES. 

be  ascribed  to  the  seat  or  nature  of  the  injury,  or  to  the  condition  of  the 
patient.  All  these  things  have  yet  to  be  determined ;  and  I  believe 
that  years  of  patient  and  well-directed  investigation  will  be  requisite  for 
them.  I  can  do  little  more  than  point  out  the  modes  in  which  the  ossi- 
fication may  be  accomplished. 

And,  first,  it  may  be  accomplished  through  perfect  fibrous  tissue. 
Thus  I  found  it  in  a  case  of  fracture  of  the  lower  part  of  the  femur  after 
six  weeks,  and  in  a  fracture  of  the  radius  after  about  nine  weeks  ;  thus, 
too,  I  think,  whatever  new  bone  is  formed  after  fractures  of  the  skull 
is  developed ;  and  thus  one  may  find,  in  the  neighborhood  of  fractures 
and  other  injuries  of  bone,  ossifications  of  interosseous  fibrous  mem- 
branes, and  of  the  tissue  of  the  periosteum,  or  just  external  to  it.* 

But,  secondly,  the  new  bone  may  be  formed  by  ossification  of  the 
fibrous  tissue  in  a  rudimental  state.  And  this  rudimental  state  may  be 
that  of  either  nucleated  cells  or  nucleated  blastema.  Through  nu- 
cleated cells  and  the  intercellular  substance  between  them,  as  the 
embryo  forms  of  fibrous  tissue,  bone  is  formed  when  granulations  or  in- 
flammatory exudations  ossify.  The  process  may  be  often  seen  in  the 
union  of  compound  fractures,  or  of  simple  ones  when  much  inflamma- 
tion has  been  excited.  But,  best  of  all,  though  here  only  for  illustra- 
tion of  what  may  occur  in  fractures,  the  ossification  of  nucleated  cells, 
with  their  intercellular  substance,  in  granulations,  may  be  observed, 
when  bone  is  formed  in  the  mushroom-shaped  mass  of  granulations  that 
is  protruded  through  the  medullary  canal  of  a  bone  sawn  across  in  an 
amputation. t  In  all  these  cases  there  appears  to  be  a  direct  transfor- 
mation into  bone,  without  the  intervention  of  either  cartilage  or  perfect 
fibrous  tissue. 

The  ossification  of  nucleated  blastema,  such  as  I  have  described  as  a 
rudimental  form  of  fibrous  tissue,  may  also  be  seen  in  simple  fractures ; 
and  my  impression  is,  that  it  is  an  ordinary  mode  of  ossification  in 
simple  fractures  of  adult  long  bones  that  unite  well  and  quickly.  In 
such  a  case,  in  a  fracture  of  the  tibia  of  five  weeks  date,  I  found,  in 
long-continued  examinations,  that  the  bone  is  formed  without  any  inter- 
mediate state  of  cartilage ;  a  finely  and  very  closely  granular  osseous 
deposit  taking  place  in  the  blastema,  and  gradually  accumulating  so  as 
to  form  the  delicate  yet  dense  lamellae  of  fine  cancellous  tissue.  The 
nuclei  of  the  blastema  appeared  to  be  inclosed  in  the  new-forming  bone, 
and  I  thought  I  could  trace  that  they  became  the  bone-corpuscles ;  but 
I  could  not  be  sure  of  this.  Yet  the  belief  is  justified  by  the  opinion 
now  entertained  by  many  physiologists  that,  in  the  normal  development 
of  bone  out  of  fibrous  membrane,  the  cells  of  the  connective  tissues 
become  the  corpuscles  of  the  bone. 

*  The  thin  plate  of  bone  which  closes  in  the  exposed  medullary  canal  of  the  end  of  a 
fractured  long  bone,  where  one  fragment  overlaps  another,  will  usually,  I  think,  present  a 
good  example  of  ossification  of  fibrous  tissue. 

t  College  Museum,  Nos.  552,  553. 


REPAIR    OF    FRACTURES.  179 

Thus,  the  new  material  produced  for  the  repair  of  fractures  may  be 
ossified  through  an  intermediate  fibrous  stage.  In  other  instances  it 
may  pass  through  a  cartilaginous  stage.  In  animals,  perfect  cartilage, 
with  its  characteristic  homogeneous  intercellular  substance,  its  cells, 
and  all  the  characters  of  pure  foetal  cartilage,  may  be  produced. 
Through  the  ossification  of  such  cartilage,  Miescher*  and  Voetsch,t 
and  others,  describe  the  repair  of  fractures  as  accomplished  in  dogs, 
pigeons,  and  other  animals  ;  and  A.  Wagner|  has  noticed,  in  his  ex- 
periments on  the  resection  of  bones  in  rabbits  and  pigeons,  a  process 
of  repair  of  a  closely  corresponding  nature.  I  have  not  yet  found  the 
very  same  process  in  the  human  subject ;  but  I  should  think  it  would 
occur  in  favorable  instances  of  simple  fracture  in  children.  In  youths 
and  adults,  I  have  found  only  varieties  of  fibrous  cartilage  ;  and  these 
have  presented  numerous  gradations  from  the  fibrous  towards  the  per- 
fect cartilaginous  structure.  In  different  specimens,  or  sometimes  even 
ip.  different  parts  of  the  same,  the  reparative  material  has  displayed,  in 
one,  fibrous  tissue,  with  a  few  imbedded  corpuscles,  like  the  large  nearly 
round  nuclei  of  cartilage-cells  ;  in  another,  a  less  appearance  of  fibrous 
structure,  with  more  abundant  nucleated  cells,  having  all  the  characters 
of  true  cartilage-cells ;  and  in  a  third,  a  yet  more  nearly  perfect  carti- 
lage.§ 

Through  any  of  these  structures  the  reparative  new  bone  may  be 
formed.  It  may  be  formed,  first,  where  the  reparative  material  is  in 
contact  with  the  old-  bone,  and  thence  extending  it  may  seem  as  if  it 
grew  from  the  old  bone  ;  or  it  may  be  formed  in  the  new  material,  in 
detached  centres  of  ossification,  from  which  it  may  extend  through  the 
intervening  tissues,  and  connect  itself  with  the  old  bone  (see  Figs.  21 
and  23). 

The  new  bone,  through  whatever  mode  it  is  formed,  appears  to  acquire 
quickly  its  proper  microscopic  characters.  Its  corpuscles  or  lacunae,  being 
first  of  simple  round  or  oval  shape,  and  then  becoming  jagged  at  their 
edges,  subsequently  acquire  their  canals,,  which  appear  to  be  gradually 
hollowed  out  in  the  preformed  bone,  as  minute  channels  communicating 
with  one  or  more  of  the  lacunae.  The  laminated  canals  for  bloodvessels 
are  later  formed.  At  first,  all  the  new  bone  forms  a  minutely  cancel- 
lous structure,  which  is  light,  spongy,  soft,  and  succulent,  with  a  red- 
dish juice  rather  than  marrow,  and  is  altogether  like  foetal  bones  in 

*  De  Inflamniatione  Ossium,  1836.  "f  Die  Heilung  der  Knochenbriiche,  1847. 

J  Essay  translated  for  the  New  Syd.  Soc,  1859.  The  statements  in  the  text  are  also  con- 
firmed generally  by  Wedl  in  his  Pathological  Histology. 

^  1  do  not  describe  the  minute  methods  of  ossification  occurring  in  the  callus,  or  repara- 
tive material ;  for  my  opportunities  of  studying  it  in  man  have  been  too  few^  for  me  to  con- 
clude from  :  and,  although  I  have  seen  nothing  opposed  to  the  belief  that  the  normal  methods 
of  ossification  are  imitated,  yet  the  process  seems  capable  of  so  many  modifications  that  I 
tliink  it  would  not  be  safe  to  adapt,  unconditionally,  to  the  case  of  the  reparative  material  in 
man,  such  conclusions  as  are  drawn  from  the  normal  ossification  of  his  skeleton,  or  from  the 
ossification  of  the  reparative  material  in  lower  animals. 


180  REPAIR     OF    FRACTURES. 

their  first  construction.  But  this  gradually  assimilates  itself  to  the 
structure  of  the  bones  that  it  repairs  ;  its  outer  portions  assuming  a 
compact  laminated  structure,  and  its  inner  or  central  portions  acquiring 
wider  cancellous  spaces,  and  a  more  perfect  medulla.  It  acquires,  also, 
a  defined  periosteum,  at  first  firm,  thin,  and  distinctly  lamellar,  and 
gradjially  assuming  toughness  and  compactness.  But,  in  regard  to  many 
of  these  later  changes  in  the  bonds  of  union  of  fractures,  there  are  so 
many  varieties  in  adaptation  to  the  peculiarities  of  the  cases,  that  no 
general  account  of  them  can  be  rendered.* 

A  subject  of  chief  interest  in  the  repair  of  fractures  is  the  position 
of  the  reparative  material,  and  in  relation  to  this  we  find  a  greater  dif- 
ference than  any  yet  mentioned  between  the  processes  traced  respec- 
tively in  man  and  in  the  animals  submitted  to  experiments. 

There  are  two  principal  methods  according  to  which  the  reparative 
material,  or  callus,  may  be  placed.  In  one,  the  broken  ends  or  smaller 
fragments  of  the  bone  are  completely  inclosed  in  the  new  material ;  they 
are  ensheathed  and  held  together  by  it,  as  two  portions  of  a  rod  might 
be  by  a  ferrule  or  ring  equally  fastened  around  them  both.  In  such  a 
case,  illustrated  by  Fig.  21,  the  new  material,  surrounding  the  fracture, 
has  been  usually  called  "provisional  callus,"  or  "external  callus:"  but 
the  term  "  ensheathing  callus"  will,  I  think,  be  more  explanatory.  In 
the  other  method  (as  in  Figs.  22  and  23),  the  new  material  is  placed  only 
between  those  parts  of  the  broken  bone  whose  surfaces  are  apposed ; 
between  these  it  is  inlaid,  filling  the  space  that  else  would  exist  between 
them,  or  the  angle  at  which  one  fragment  overhangs  another,  and 
uniting  them  by  being  fixed  to  both.  Reparative  material  thus  placed 
maybe  called  "intermediate  callus."  In  either  method  (as  in  Figs. 
21  and  22),  there  is  usually  some  reparative  material  deposited  in  and 
near  the  broken  medullary  tissue ;  and  this  may  be  still  named  "  inte- 
rior callus." 

The  method  of  repair  with  an  ensheathing  or  provisional  callus  is 
rarely  observed  in  man,  but  appears  to  be  frequent  in  fractures  of  long 
bones  in  animals, f     From  these  it  has  been  admirably  described  by 

*  Many  very  excellent  observations  have  been  made  in  France,  of  late  years,  by  Flourens, 
Oilier,  Demarquay,  and  others,  illustrating  the  importance  of  the  periosteum  in  the  formation 
of  new  bone.  Their  experiments  have  shown  not  only  that  large  portions  of  the  shaft  of  a 
bone  may  be  reproduced  if  the  periosteum  is  not  removed,  but  that  bone  may  be  made 
to  grow  in  a  part  not  customary,  by  transplantation  of  a  portion  of  periosteum.  By  these 
observations,  the  principles  of  DuHamel  as  to  the  reproduction  of  bone  have  been  extended, 
and  the  facts  long  ago  proved  by  Syme  have  been  corroborated  by  more  remarkable  in- 
stances. A  somewhat  different  interpretation  of  the  regenerative  power  of  the  periosteum, 
has  been  put  forward  by  Prof  Goodsir.  (Anat.  and  Path.  Observ.)  He  argues  that  it  is 
impossible  to  separate  the  periosteum  in  living  animals  without  detaching  minute  shreds  of 
bone  along  with  it,  and  that  it  is  from  these  shreds,  rather  than  from  the  periosteum  itself, 
that  the  regenerative  process  is  set  up. 

f  Even  in  animals  it  is  not  constant.  To  obtain  what  would  be  called  good  specimens 
of  provisional  callus,  the  injuries  must  be  inflicted  upon  young  animals,  and  among  these  I 
cannot  but    suspect  that  particular  instances  have  been  selected  for  description  ;   those  in 


REPAIR     OF    FRACTURES. 


181 


Fie;.  21. 


Dupuytren  and  others.  The  chief  features  of  the  process  are  as  fol- 
lows (omitting  dates,  which  have  not  been  ascertained  in  man,  and  can- 
not well  be  calculated  for  him) : 

In  the  simplest  case,  when  the  fragments  (as  represented  in  this  dog's 
tibia :  Fig.  21)  lie  nearly  in  apposition,  and  nearly  correspond,  the  re- 
parative material  accumulates  at  once  around  and  within  them,  and  in 
any  interspaces  that  may  be  left  between  them.  That  around  them,  that 
is,  the  en  sheathing  callus,  forms  most  quickly 
and  in  greater  abundance,  and  lies  chiefly  or 
solely  between  the  wall  of  the  bone  and  the  peri- 
osteum, which  is  thus  lifted  up  from  the  wall,  the 
bloodvessels  that  passed  from  it  into  the  bone 
now  passing  to  their  destinations  through  the 
callus.  The  distance  from  the  broken  ends  to 
which  the  callus  extends  up  each  fragment  is 
uncertain  ;  in  the  long  bones  of  dogs,  and  the 
ribs  of  men,  it  is  usually  about  half  an  inch. 
The  thickness  of  the  callus  is  greatest  at  a  little 
distance  from  the  plane  of  the  fracture  :  exactly 
in  that  plane  it  is  usually  less  thick  than  either 
above  or  below  ;  so  that,  even  when  it  is  ossified, 
it  is  often  marked  with  a  slight  annular  con- 
striction. 

The  interior  callus  fills  up  the  spaces  in  the 
cancellous  tissue,  extending  in  the  medullary 
canal  of  each  fragment  to  a  distance  somewhat 
short  of  that  to  which  the  ensheathing  callus 
reaches.  At  the  end  of  each  fragment  there  is 
usually  an  abrupt  contrast  between  the  firm  re- 
parative material  that  forms  this  interior  callus, 
and  a  softer  substance,  like  that  of  granulations, 
which  remains  between  the  fragments  even  till 
the  callus  without  and  within  is  quite  ossified. 
As  the  section  drawn  in  Fig.  21  shows,  the  re- 
parative material  is  abundant  and  well  developed 

both  around  and  within  the  fragments :  but  between  them,  i.  e.  in  the 
plane  of  the  fracture,  it  is  sparingly  formed  and  soft,  so  that  the  frag- 
ments, if  the  ensheathing  callus  were  removed,  would  be  no  longer  held 
together  ;  they  are,  in  fact,  combined  long  before  they  are  united. 

The  ossification  of  the  ensheathing  callus  is  accomplished  chiefly  or 

which  less  callus  was  formed  having  been  put  aside  as  imperfect  instances  of  repair,  though, 
in  truth,  they  may  have  displayed  the  more  natural  process.  Such  good  specimens  are,  in 
the  Museum  of  the  College,  Nos.  418  to  426  ;  and  in  that  of  St.  Bartholomew's,  Ser.  iii,  69,  70, 
71,  96,  81,  82,  92,  106.  Fig.  21  is  drawn  from  No.  96.  It  is  very  desirable  to  obtain  exami- 
nations of  fractured  long  bones  recently  united  in  young  children  ;  for  it  is  probable  that  in 
these  the  process  would  be  very  like  that  described  from  the  experiments  on  animals.  No 
opportunity  for  such  an  examination  has  yet  occurred  to  me. 


182  REPAIR    OF    FRACTURES. 

solely  by  outgrowth  of  bone  from  the  fragments  on  whicb  it  is  placed. 
Here,  also,  the  same  method  of  progress  is  observed,  in  that  the  for- 
mation of  new  bone  extends  gradually  towards  that  part  of  the  callus 
which  exactly  corresponds  with  the  plane  of  the  fracture.  This  part  of 
the  callus  is  last  ossified;  but,  at  length,  its  ossification  being  complete, 
the  fragments  are  combined  by  and  within  a  sheath  or  ferrule  of  new 
bone.  The  interior  callus,  ossifying  at  about  the  same  time,  consoli- 
dates the  cancellous  tissue  of  the  fragments,  and,  at  a  later  period, 
unites  them.  The  walls  remain  still  longer  disunited.  The  ossified 
callus  is,  indeed,  sufficient  to  render  the  bone  fit  for  its  office,  but  it 
retains  the  nearly  cancellous  tissue  of  new  bone,  and  it  is  still  only 
provisional :  for  when  the  walls  of  the  fragments  are  themselves  united, 
and  their  continuity  is  restored,  all,  or  a  part,  of  the  external  callus  is 
removed,  and  the  cancellous  tissue  loses  its  solidity  by  the  removal  of 
the  internal  callus. 

Such  is  the  process  of  repair  with  an  ensheathing  callus.  It  is,  as 
I  have  said,  usual  in  animals ;  but  in  man  I  have  never  seen  its  occur- 
rence as  a  natural  process  in  any  bones  but  the  ribs.  In  these  it  may 
be  traced  as  perfectly  as  I  have  described  it  from  the  instances  of 
repaired  fractures  of  long  bones  in  the  rabbit  and  dog.  Sometimes, 
indeed,  a  similar  process  occurs  in  other  human  bones.  I  have  seen  it 
in  the  clavicle  and  humerus  ;*  but  in  both  these  cases  the  more  proper 
mode  of  repair  had  been  disturbed  by  constant  movement  of  the  parts, 
and  in  the  humerus  the  process  had  manifest  signs  of  exaggeration 
and  disease. 

The  normal  mode  of  repair  in  the  fractures  of  human  bones  is  that 
which  is  accomplished  by  "intermediate  callus."  The  principal  features 
of  difference  between  it  and  that  just  described  are,  (1)  that  the  repara- 
tive material  or  callus  is  placed  chiefly  or  only  between  the  fragments, 
not  around  them ;  (2)  that,  when  ossified,  it  is  not  a  provisional,  but  a 
permanent,  bond  of  union  for  them ;  (3)  that  the  part  of  it  which  is 
external  to  the  wall  of  the  bone  is  not  exclusively,  or  even  as  if  with 
preference,  placed  between  the  bone  and  the  periosteum,  but,  rather, 
in  the  tissue  of  the  periosteum,  or  indifierently  either  in  it,  beneath  it, 
or  external  to  it. 

When  the  fragments  are  placed  in  close  apposition  and  correspon- 
dence, they  may,  I  believe,  be  joined  by  immediate  union  ;  but  if  this  do 
not  happen,  a  thin  layer  of  reparative  material  is  deposited  between 
them ;  it  does  not,  in  any  direction,  exceed  the  extent  of  the  fracture ; 
neither  does  it,  in  more  than  a  trivial  degree,  occupy  the  medullary 
canal ;  but,  being  inlaid  between  the  fragments,  and  there  ossifying,  it 

*  Museum  of  St.  Bartholomew's,  Ser.  iii,  92,  65,  and  66.  The  clavicle  was  broken  twelve 
weeks  before  death ;  but  the  fracture  was  not  detected,  and  the  fragments  were  allowed  to 
move  unrestrained.  The  humerus  was  taken  from  a  man  who  died  some  weeks  after  the 
fracture,  and  whose  arm  had,  for  several  days  after  the  injury,  been  the  seat  of  severe 
spasms.     See  Mr,  Stanley's  '•Illustrations  of  Diseases  of  Bones,"  pi.  xxiii,  fig.  3, 


REPAIR    OF    FRACTURES. 


183 


restores  their  continuity.     The  process  may  be  compared  with  that  of 
union  by  primary  adhesion. 

When,  as  more  commonly  happens,  the  fragments,  though  closely 
apposed,  do  not  exactly  correspond,  but,  at  certain  parts,  project  more 
or  less  one  beyond  the  other,  the  reparative  material  is,  as  in  the  for- 
mer case,  inlaid  between  them,  and  to  a  slight  extent,  in  the  medullary 
canal ;  but  it  is  also,  in  larger  quantity,  placed  in  the  angles  at  which 
the  fragments  overhang  one  another.  Its  position  is,  in  these  cases, 
well  shown  in  the  specimens  drawn  in  the  22d  and  23d  figures.     In 


Fig.  22. 


Fig.  23. 


the  fractured  radius*  (Fig.  22)  the  carpal  portion,  laterally  displaced, 
projects  beyond  the  radial  margin  of  the  upper  and  impacted  portion ; 
and  the  angle  between  them  is  exactly  filled,  without  being  surpassed, 
by  a  wedge-shaped  mass  of  reparative  material.  So,  but  less  perfectly, 
is  the  angle  on  the  ulnar  side.  In  the  fractured  femurf  (Fig.  28),  with 
great  displacement  of  the  fragments,  the  same  rule  is  observed ;  the 
interspace  between  the  fragments,  and  parts  of  the  angles  at  which  the 
one  projects  beyond  the  other,  are  filled  with  partially  ossified  repara- 


*  Museum  of  St.  Bartholomew's,  Ser.  iii,  No.  94. 
f  The  same  Museum,  Ser.  iii.  No.  103. 


184  REPAIE    OF    FRACTURES. 

tive  material.  In  neither  case  is  there  an  ensheathing  callus ;  in 
neither  is  any  reparative  material  placed  on  that  aspect  of  the  one 
fragment  which  is  turned  from  the  other. 

Lastly,  when  the  fragments  neither  correspond  nor  are  apposed, 
when  one  completely  projects  beyond  or  overlaps  another,  and  when,  it 
may  be,  a  wide  interval  exists  between  them,  still  the  reparative  ma- 
terial is  only  placed  between  them.  It  just  fills  the  interval ;  it  does 
not  even  cover  the  ends  of  the  fragments,  or  fill  any  part  of  the  medul- 
lary canal:  much  less  does  it  inclose  both  the  ends  of  the  mutually 
averted  surfaces,  as  the  provisional  callus  would  in  a  similar  fracture  in 
a  dog  or  a  rabbit ;  it  passes,  bridge-like,  from  one  fragment  to  the 
other,  and  thus,  when  ossified,  combines  them.  Thus  it  appears  in  the 
fractured  femur,  part  of  which  is  represented  in  Fig.  21.* 

The  three  instances  which  I  have  cited,  of  difierent  relative  positions 
of  the  fragments,  may  suffice  as  examples  of  classes  in  which  nearly  all 
simple  fractures  of  long  bones  might  be  described.  But,  whether  the 
displacement  were  like  either  of  these,  or  of  any  other  kind,  I  have 
seen  no  examples  (other  than  the  exceptions  already  mentioned)  in 
which  the  reparative  material  has  been  placed  according  to  a  different 
method. f  It  is  always  an  intermediate  bond  of  union ;  it  is  inlaid  be- 
tween the  fragments ;  and  when  formed  in  largest  quantity,  is  only 
enough  to  smooth  the  chief  irregularities,  and  to  fill  up  the  interspaces 
and  angles  between  them.  And,  regarding  the  particular  position 
which  it  may  in  each  case  occupy,  I  do  not  know  that  it  can  be  more 
exactly  described,  than  by  saying,  that  it  is  deposited  where  it  is  most 
wanted  for  the  strengthening  of  the  bone ;  so  that,  wherever  would  be 
the  weak  part,  if  unhealed,  there  is  the  new  material  placed,  in  quantity 
as  well  as  in  position  just  adapted  to  the  exigencies  of  the  case,  and 
restoring,  as  much  as  may  be,  the  original  condition  and  capacities  of 
the  bone. 

If,  now,  it  be  inquired  why  this  difi"erence  should  exist  in  the  cor- 
responding processes  in  man  and  other  animals,  I  believe  it  must  be 
ascribed  principally  to  two  causes,  namely,  the  quietude  in  which  frac- 

*  Museum  of  St.  Bartholomew's  Hospital,  Ser.  iii,  No.  98. 

f  I  exhibited  at  this  lecture  all  the  specimens  of  fractures  examined  within  six  rnonths 
of  the  injury  that  are  contained  in  the  Museums  of  the  College  and  St.  Bartholomew's;  and 
they  all,  with  the  exceptions  already  mentioned,  exemplified  this  account  of  the  repair  by 
intermediate  caihis,  and  of  the  absence  of  provisional  or  ensheathing  callus.  They  included 
a  radius,  four  weeks  after  the  fracture;  another,  four  or  five  weeks;  a  tibia,  five  weeks;  a 
femur,  six  weeks;  another  of  the  same  date;  a  third  of  about  eight  or  nine  weeks;  a  radius, 
of  somewhat  later  date;  a  tibia,  eight  weeks;  a  fibula,  eleven  weeks;  a  tibia,  twelve 
weeks;  a  tibia,  sixteen  weeks  after  the  injury;  and  many  others  of  various  but  unknown 
dates,  all  in  process  of  apparently  natural  repair.  Since  the  lecture  was  given,  the  descrip- 
tion has  been  confirmed  by  many  examinations  by  myself  and  others.  My  conclusions 
respecting  the  absence  of  ensheathing  callus  in  the  ordinary  repair  of  fractures,  are  fully 
confirmed  by  the  observations  of  Dr.  H.  Hamilton,  which  were  conducted  at  the  same  time 
as  mine,  and  led  him,  independently,  to  the  same  conclusion.  See  his  Essay  in  the  Buffalo 
Medical  Journal  for  February,  1853. 


REPAIR    OF    FRACTURES.  185 

turesin  our  bones  are  maintained,  and  the  naturally  greater  tendency  to 
the  production  of  new  bone  which  animals  always  manifest.  Even  in- 
dependently of  surgery,  in  the  case  of  fractures  of  the  lower  extremity, 
the  human  mode  of  progression  almost  compels  a  patient  to  take  rest : 
and  in  fractures  of  the  upper  extremity,  the  circumstances  of  human 
life  and  society  permit  him  to  do  so  far  more  than  other  animals  can. 
The  whole  process  of  repair  is,  therefore,  more  quietly  conducted  ;  and, 
as  we  may  say,  there  is  comparatively  little  need  of  the  strength  which 
the  formation  of  provisional  callus  would  give  a  broken  limb. 

The  exceptions  to  the  rule,  of  difference  in  the  repair  of  human  bones 
and  those  of  animals,  confirm  it  as  thus  explained ;  for  they  are  found 
in  the  ribs,  which  are  certainly  never  kept  at  rest  during  all  the  time 
necessary  for  repair  after  fracture,  and  in  bones  of  which,  from  various 
causes,  the  repose  of  the  fragments  has  been  disturbed,  or  which  have 
been  the  seats  of  disease,  with  inflammatory  deposit,  during  or  sub- 
sequent to  the  reparative  process. 

The  comparative  restlessness  of  animals  is,  however,  I  think,  not 
alone  sufficient  to  account  for  all  the  difi'erence  in  the  processes.  The 
remainder  may  be  ascribed  to  their  greater  tendency,  in  all  circum- 
stances, to  the  formation  of  new  bone.  Not  in  fractures  alone,  but  in 
necrosis  this  is  shown.  It  is  very  rarely  that  such  quantities  of  new 
bone  are  formed  in  even  children,  as  are  commonly  produced  after 
necrosis  of  the  shafts  of  bones  in  dogs  or  other  animals  ;  nor  is  there 
in  the  human  subject  any  such  filling  up  of  the  cavities  from  which 
superficial  sequestra  have  been  separated,  as  the  experiments  of  Mr. 
Hunter  showed,  after  such  exfoliations  from  the  metatarsal  bones  of 
asses.* 

It  remains,  now,  that  I  should  describe  the  later  part  of  the  repair  of 
fractures, — that  which  consists  in  the  shaping  or  modelling  of  the  frag- 
ments and  of  their  bond  of  union. 

Omitting  the  removal  of  the  provisional  callus,  where  such  a  one  has 
been  formed,  this  modelling  is  best  observed  when  there  has  been  much 
displacement  of  the  fragments.  In  these  cases,  the  chief  things  to  be 
accomplished  are,  1st,  the  removal  of  sharp  projecting  points  and  edges 
from  the  fragments ;  2dly,  the  closing  or  covering  of  the  exposed  ends 
of  the  medullary  tissue  ;  3dly,  the  forming  a  compact  external  wall, 
and  cancellous  interior,  for  the  reparative  new  bone  ;  and  lastly,  the 
making  these  continuous  with  the  walls  and  cancellous  tissue  of  the 
fragments. 

*  Museum  of  the  College,  Nos.  64  L  to  653. 

The  denial  of  the  formation  of  an  ensheathing  callus  in  the  repair  of  fractures  is  some- 
times met  by  the  statement  that  such  a  callus  can  be  often  felt  during  life.  The  deception 
is  produced  either  by  thickening  and  induration  of  the  soft  parts  around  the  fracture;  or  by 
tlie  two  overlapping  ends  of  the  fragments  being  grasped  at  once ;  or,  much  more  rarely, 
by  new  bone  accumulated  about  the  fragments  in  consequence  of  inflammation. 

13 


186 


EEPAIR     or    FRACTURES. 


Fig.  24. 


The  first  of  these  is  effected  by  the  absorption  of  the  offending  points 
and  angles  ;  and  an  observation  sent  to  me  by  Mr.  Delagarde  tells  much 
of  the  process:  "A  patient  in  the  Exeter  Hospital  had  a  bad  com- 
minuted fracture  of  the  leg,  and  a  long  spike   of  the  tibia,  including 

part  of  its  spine,  could  not  be  reduced  to  its 
exact  level,  but  continued  sensibly  elevated, 
though  in  its  due  direction.  At  the  end  of 
five  weeks  (union  having  taken  place)  the 
end  of  the  spike  began  to  soften  ;  at  six,  it 
was  quite  soft  and  flexible,  like  a  thin  carti- 
lage ;  at  the  conclusion  of  the  seventh  week 
it  was  blunt  and  shrunken.  Six  months 
later,  the  cartilaginous  tip  had  disappeared, 
and  the  spike  was  rounded  off." 

I  have  since,  in  a  similar  case,  seen  the 
same  process  repeated.  Both  cases  seem  to 
show  that  the  absorption  of  the  bone  is  ac- 
complished, as  Mr.  Hunter  described  it  in 
cases  of  necrosis,  by  removing  first  the 
earthy  matter,  and  then  the  softened  re- 
mains of  animal  substance. 

The  closing  or  covering  in  of  the  parts  of 
the  broken  medullary  tube,  which  are  ex- 
posed in  fractures  with  much  displacement, 
is  slowly  accomplished  by  the  formation  of  a 
thin  layer  of  compact  bone,  like  that  which 
covers  the  cancellous  tissue  at  the  articular 
ends  of  bones.  It  is  well  shown  in  the  ori- 
ginal of  the  24th  figure.*  In  a  fracture  of 
the  femur,  after  six  weeks,  I  have  seen  the 
exposed  medullary  tube  covered  in  with  a 
thin  fibrous  membrane,  tense  like  a  drum- 
head, new-formed,  and  continuous  with  the 
periosteum.  The  permanent  closure  appearsi 
to  be  effected  by  the  ossification  of  such  a  membrane ;  and  the  new  bone 
becomes  smoothly  continuous  with  the  rounded  and  thinned  broken  mar- 
gins of  the  walls  of  the  old  bone.  So  are  the  ends  of  stumps  covered 
in  ;  and  neither  in  these  nor  in  fractures  have  I  seen  new  bone  extending 
into  the  medullary  canal,  as  if  formed  by  the  ossification  of  an  internal 
callus. 

The  same  sketch  shows  the  nearly  completed  formation  of  distinct 
walls  and  medullary. tissue  in  the  bridge  of  new  bone  connecting  the 
two  fragments  of  the  femur.  At  an  earlier  period  we  may  be  sure  that 
all  this  new  bone  was  soft  and  cancellous ;  it  has  now  acquired  the  tex- 


*  From  the  Museum  of  St.  Bartholomew's,  Ser.  iii,  No.  98. 


REPAIR     OP    FRACTURES.  187 

tures  proper  to  the  bone  which  it  repairs,  and,  as  if  to  complete  its 
conformity  with  the  structures  among  which  it  was  thus,  by  accident, 
introduced,  the  process  was  begun  by  which  the  new  and  the  old  com- 
pact and  medullary  tissues  would  become  respectively  continuous.  Al- 
ready those  parts  of  the  walls  of  the  shaft  that  intervene  like  partitions, 
separating  the  new  from  the  old  medullary  tissues,  are  thin,  uneven  on 
their  surfaces,  and  in  their  interior  half-cancellous.  At  some  later 
time  they  would,  probably,  have  been  reduced  to  mere  cancellous  tissue, 
and  the  repair  of  the  fracture  would  have  been  completed,  crookedly 
indeed,  but  with  unbroken  continuity  of  tissue. 

To  adapt  the  foregoing  account  to  the  case  of  compound  fractures,  it 
is,  I  believe,  only  necessary  (so  far  at  least  as  the  normal  process  of 
repair  is  concerned)  to  say  that  the  reparative  material  is  more  mingled 
with  products  of  inflammation ;  that  that  part  of  it  which  is  formed 
Avithin  reach  of  the  air,  or  in  a  suppurating  cavity,  is  developed  to  bone 
through  the  medium  of  granulations,  like  those  formed  in  open-  wounds 
of  soft  parts ;  and  that  the  whole  process  of  repair  is,  generally,  slower, 
less  secure,  and  more  disturbed  by  morbid  growths  of  bone,  and  other 
effects  of  what  has  been  named  "  ossific  inflammation." 

The  data,  at  present  collected,  concerning  the  times  in  which  the 
several  parts  of  the  reparative  process  are  usually  completed  after  frac- 
tures of  adult  human  bones,  are  not  sufficient  for  more  than  a  general 
and  approximate  estimate.  They  may  be  thus  generally  reckoned. 
To  the  second  or  third  day  after  the  injury,  inflammatory  exudation  in 
and  about  the  parts  ;  thence  to  the  eighth  or  tenth,  seeming  inaction, 
with  subsidence  of  inflammation  ;  thence  to  about  the  twentieth,  pro- 
duction of  the  reparative  material,  and  its  gradual  development  to  its 
fibrous  or  cartilaginous  condition;  thenceforward  its  gradual  ossifica- 
tion, a  part  of  the  process  which  is,  however,  most  variable  in  both  its 
time  of  commencement  and  its  rate  of  progress,  and,  which  is,  probably, 
rarely  completed  before  the  ninth  or  tenth  week,  although  the  limb  may 
have  long  previously  recovered  its  fitness  for  support  or  other  use. 
From  this  time  the  rate  of  change  is  so  uncertain,  that  it  is  impossible 
to  assign  the  average  time  within  which  the  perfection  of  the  repair  is, 
if  ever,  accomplished. 

The  consequences  of  failure  in  the  process  of  repair  may  be  illus- 
trated by  what  I  have  described  as  its  normal  course.  In  a  large  part 
of  the  cases  of  ununited  fracture  the  fragments  are  connected  by  fibrous 
or  fibro-cartilaginous  tissue,  inlaid  between  them.  Such  is  the  defec- 
tive union  of  most  cases  of  fracture  of  the  neck  of  the  femur  within 
the  capsule,  and  of  the  olecranon  and  the  patella  when  their  fragments 
are  not  held  close ;  and  such  a  defect  may  occur  in  any  long  bone.  It 
is  an  example  of  arrested  development  of  the  reparative  material ;  and 
may  be,  in  this  respect,  compared  with  the  condition  of  granulations 


188  REPAIR    OF    FRACTURES. 

whose  cells  persist  in  their  rudimental  form.  Every  other  part  of  the 
process  may  be  complete ;  but  this  part  fails,  and  the  fragments  are 
combined  by  a  yielding,  pliant,  and  almost  useless  bond. 

In  other  cases,  the  failure  seems  to  occur  earlier.  l^To  reparative 
material  is  formed,  and  the  fragments  remain  quite  disunited.  This 
may  be  the  result  of  accidental  hindrances  of  the  normal  reparative 
process :  but.  it  sometimes  appears  like  a  simple  defect  of  formative 
power ;  a  defect  which,  I  believe,  cannot  be  explained,  and  which  seems 
the  more  remarkable  when  we  observe  the  many  changes  which  may, 
at  a  later  time,  be  effected,  as  if  to  diminish  the  evil  of  the  Avant  of 
union.  Thus,  commonly,  the  ends  of  bones  thus  disunited  become 
covered  with  a  thin  layer  of  fibrous  tissue,  polished  as  if  with  a  cover- 
ing of  epithelium,  and  as  smooth  as  an  articular  surface  :  similar  smooth 
linings  form  in  the  cavities  that  inclose  them ;  the  tissues  immediately 
around  them  become  condensed  and  fibrous ;  and  thus,  at  length,  the 
ends  of  the  fragments  are  brought  to  the  imitation  of  a  joint,  in  which 
they  may  move  without  mutual  injury.  Or,  else,  in  the  place  of  such 
a  false  joint,  the  end  of  each  fragment  has  a  kind  of  bursal  sac  formed 
on  it,  protecting  the  adjacent  parts  from  injury  in  its  movements.  But, 
much  as  may  be  thus  accomplished,  new  bone  is  not  spontaneously  pro- 
duced. As  the  result  of  disease,  it  may  be  formed  ;  and  in  this  case  it 
is  often  formed  uselessly,  and  without  evident  design,  in  heaps  or  no- 
dules about  the  ends  of  the  fragments ;  yet  it  is  of  such  disease  that 
surgery  may  often  make  happy  use  when  it  can  excite  inflammation  of 
the  fragments,  and  so  hold  them  close  that  the  new  bone  may  grow  be- 
tween or  around  them,  and  fasten  itself  to  both.* 

*  It  will  diminish  the  defects  of  the  foregoing  description  of  the  repair  of  fractures,  which 
I  have  drawn  almost  entirely  from  my  own  observations,  if  I  subjoin  a  Ust  of  the  works  es- 
pecially or  chiefly  devoted  to  this  subject,  in  which  the  reader  may  find  the  best  help  to  a 
larger  knowledge  of  the  subject. 

Dupuytren  :  Expose  de  la  Doctrine  de  M.  Dupuytren  sur  le  Cal,  par  Sanson.  In  Jour. 
Univ.  des  Sciences  M6dicales,  t.  xx. 

Breschet :  Recherches  ....  sur  la  Formation  du  Cal ;  Thfese.     Paris,  1819. 

Howship  :  On  the  Union  of  Fractured  Bones.     Med.  Chir.  Trans,  vol.  ix. 

Miescher :  De  Inflammatione  Ossium  eorumque  Anatome.     Berlin,  1836. 

Flourens:  Sur  le  Developpement  des  Os  et  des  Dents.     Paris,  1842. 

Lebert:  Sur  la  Formation  du  Cal-.     In  his  Physiologie  Pathologique,  t.  ii,  Paris,  1845. 

Voetsch  :  Die  Heilung  der  Knochenbriiche.      Heidelberg,  1847. 

Stanley  :  Illustrations  of  the  Effects  of  Disease  and  Injury  of  the  Bones,  p.  27.      1849. 

Malgaigne  :  Traite  des  Fractures  et  des  Luxations,  t.  i.     Paris,  1847. 

Dusseau  :  Onderzoek  van  Het  Beenweefsel  en  van  Verbeeningen  in  zachte  Deelen.  Am- 
sterdam, 1850. 

Dusseau  :  De  Callasvornening  en  de  gessezing  van  Beenbrenking,  in  the  Nederlandsch 
Weekblad,  1851.  From  an  extract  in  the  Nederlandsch  Lancet,  Mai,  1852.  I  judge 
that  his  account  confirms,  in  all  essential  particulars,  what  I  have  written. 

Oilier :  On  the  Artificial  Production  of  Bone.  Brown-S^quard's  Journ.  de  Phys.,  Jan. 
1859. 

E.  Gurlt :  Handbuch  der  Lehre  v.  d.  Knochenbriichen.     Frankfort,  1860. 


HEALING    OF    CAETILAGB.  189 

LECTURE  XII. 

HEALING  OF  INJURIES  IN  VARIOUS  TISSUES. 

This  last  lecture  on  the  process  of  repair  I  propose  to  devote  to  the 
consideration  of  the  modes  of  healing  of  several  different  tissues ;  modes 
which,  although  they  be  all  consistent  with  what  has  been  said  of  the 
general  rules  and  methods  of  the  healing  process,  yet  present  each  some 
peculiarity  that  seems  worthy  of  observation. 

And  first  (though  it  matters  little  which  I  begin  with),  of  the  healing 
of  wounds  and  other  injuries  of  cartilage. 

Th'ere  are,  I  believe,  no  instances  in  which  a  lost  portion  of  cartilage 
has  been  restored,  or  a  wounded  portion  repaired,  with  new  and  well- 
formed  permanent  cartilage,  in  the  human  subject.  When  a  fracture 
extends  into  a  joint,  one  may  observe  that  the  articular  cartilage 
remains  for  a  long  time  unchanged,  or  else  has  its  broken  edges  a  little 
softened  and  rounded  off.  In  one  case,  I  saw  no  other  change  than 
this  in  six  weeks  :  but  at  a  later  period  the  gap  is  filled  with  a  tough 
fibrous  tissue ;  or  rather,  the  gap  becomes  somewhat  wider  and  shal- 
lower, and  the  space  thus  formed  is  so  filled  up. 

The  excellent  researches  of  Dr.  Redfern*  have  ascertained  the  method 
of  this  process  in  incised  wounds  of  the  articular  cartilages  of  dogs. 
As  showing  the  slowness  of  the  repair,  he  found  in  one  instance,  in 
which  he  made  three  incisions  into  the  cartilage  of  a  patella,  and  two 
into  that  of  the  trochlear  surface  of  the  femur,  that  no  union  had  taken 
place  in  twenty-nine  weeks,  l^o  unusual  cause  for  the  want  of  union 
had  been  apparent,  yet  a  reparative  process  had  but  just  commenced. 
In  another  case,  twenty-four  weeks  and  four  days  after  similar  inci- 
sions, he  found  them  completely  and  firmly  united  by  fibrous  tissue 
formed  out  of  the  substance  of  the  healthy  cartilage.  The  cut  surfaces 
of  the  cartilage  were  very  uneven,  and  were  hollowed  into  small  pits, 
produced  by  the  half-destroyed  cartilage-cells,  the  former  contents  of 
which  were  now  lying  on  the  surface.  No  evident  change  had  taken 
place  in  the  texture  of  the  cartilage  at  a  little  distance  from  the  cut 
surfaces,  except  that  here  and  there  the  i-ntercellular  substance  pre- 
sented a  fibrous  appearance.  The  substance  uniting  the  cut  surfaces 
consisted  of  a  hyaline,  granular,  and  indistinctly  striated  mass,  in  which 
were  numbers  of  rounded,  oblong,  elongating,  or  irregularly-shaped  cor- 
puscles. A  nucleated  fibrous  membrane,  formed  by  the  conversion  of 
the  superficial  layers  of  the  cartilage  bordering  the  wounds,  was  con- 
tinuous with  their  uniting  medium.  "  The  essential  parts  of  the  pro- 
cess [of  union  of  such  incised  wounds]  appear  to  be,"  Dr.  Redfern  con- 

*  Anormal  Nutrition  in  Articular  Cartilages :  Edinburgh,  1850.  And,  On  the  Healing 
of  Wounds  in  Articular  Cartilages:  in  the  Monthly  Journal  of  Medical  Science,  Sept.,  1851. 


190  HEALING    OF    TENDONS. 

eludes,  "  the  softening  of  the  intercellular  substance  of  the  cartilage, 
the  release  of  the  nuclei  of  its  cells,  the  formation  of  white  fibrous  tis- 
sue from  the  softened  intercellular  substance,  and  of  nuclear  fibres  by 
the  elongation  of  the  free  nuclei." 

Such  a  process  has  peculiar  interest  as  occurring  in  a  tissue  which 
has  no  bloodvessels,  and  in  which,  therefore,  the  reparative  material  is 
furnished  by  transformation  of  its  own  substance,  not  by  exudation  from 
the  blood.  In  the  same  view  the  results  of  inflammation  of  articular 
cartilage  will  have  to  be  particularly  noticed. 

In  membraniform  cartilages  that  have  perichondrium,  the  healing 
process  is,  probably,  in  some  measure  modified  ;  a  reparative  material 
being  furnished,  at  least  in  part,  from  the  perichondrial  vessels.  The 
cartilaginous  tissue  was  less  changed  than  in  Dr.  Redfern's  cases,  in  an 
example  of  wounded  thyroid  cartilage  that  I  examined.  A  man,  long 
before  death,  cut  his  throat,  and  the  wound  passed  about  half  an  inch 
into  the  angle  of  his  thyroid  cartilage.  In  the  very  narrow  gap  thus 
made,  a  gap  not  more  than  half  a  line  in  width,  there  was  only  a  layer 
of  tough  fibrous  tissue ;  and  with  the  microscope  I  could  detect  no  ap- 
pearance of  a  renewed  growth  of  cartilage.  The  edges  of  the  cartilage, 
to  which  the  fibrous  tissue  was  attached,  were  as  abrupt,  as  clean,  and 
as  straight  as  those  would  be  of  a  section  of  cartilage  just  made  with  a 
very  sharp  instrument.  The  cut  cartilage  was  unchanged,  though  the 
union  between  it  and  the  new-formed  fibrous  tissue  was  as  close  and  as 
firm  as  that  of  the  several  parts  of  a  continuous  tissue.  The  perichon- 
drium on  both  sides  was  equally  firmly  attached  to  the  fibrous  bond.* 

In  some  instances  (but  I  suppose  in  none  but  those  of  cartilages 
which  have  a  natural  tendency  to  be  ossified  in  advancing  years)  the 
fractures  of  cartilage  may  be  united  by  bone.  This  commonly  happens 
in  the  fractures  of  the  costal  cartilages  ;  and  it  has  been  noticed  in 
fractures  of  the  thyroid  cartilage.  The  union  of  a  fracture  of  the  car- 
tilaginous portion  of  a  rib  is  usually  efi'ected,  as  that  of  one  in  the  osse- 
ous portion  is,  by  an  inclosing  ring  of  bone,  like  a  provisional  external 
callus  ;  and  the  ossification  extends  to  the  parts  of  the  cartilage  imme- 
diately adjacent  to  the  fracture. f 

Sealing  of  Tendons. — I  have  already  often  referred  to  the  phenomena 
that  follow  the  division  of  tendons  by  subcutaneous  and  by  open  Avounds ; 
but  the  practical  interest  of  the  subject  will  justify  my  giving  a  con- 

*  A  case  has  recently  been  recorded  by  Mr.  Edwards  (Edin.  Month.  Med.  Jour.  March, 
1861),  in  which  there  was  such  complete  reunion  (apparently  cartilaginous),  of  the  tracheal 
rings  of  an  infant,  who  died  about  twelve  months  after  the  operation  of  tracheotomy  had 
been  performed,  that  no  scar  was  visible.  No  microscopic  examination  of  the  new  material 
was,  however,  made. 

f  Museum  of  the  College,  No.  377  ;  and  of  St.  Bartholomew's,  Ser.  iii,  Nos.  48,  73.  Nu- 
merous examples  of  the  partial  repair  of  larger  injuries  of  articular  and  other  cartilages  will 
be  found  in  Hiklebrandt"s  Anatomie,  B.  i,  p.  306. 


HEALING    OF    TENDONS.  191 

nectecl  account  of  the  process,  as  I  observed  it  in  a  series  of  numerous 
experiments  performed,  with  the  help  of  Mr.  Savory,  on  rabbits  from 
three  to  six  months  old.  Such  experiments  are,  I  know,  open,  in  some 
measure,  to  the  same  objection  as  I  showed  in  the  last  lecture  to  those 
on  fractures  in  the  lower  animals  ;  but  the  few  instances  in  which  ex- 
aminations have  been  made  of  human  tendons,  divided  by  subcutaneous 
section,  have  shown  that  the  processes  in  man  and  in  animals  are  not 
materially  different.  The  chief  differences  are,  we  may  believe,  that, 
as  in  the  repair  of  bones,  the  production  of  reparative  material  is  more 
abundant  and  its  organization  more  speedy,  in  animals  than  in  man. 

I  have  already,  in  the  eighth  lecture,  stated  generally  the  differences 
in  the  several  consequences  of  open  and  subcutaneous  wounds.  In  the 
case  of  divided  Achilles-tendons,  the  disadvantages  of  open  wounds,  i.  e., 
of  wounds  extending  through  the  integuments  over  and  on  each  side  of 
the  tendon,  as  well  as  through  it,  were  as  folloAvs  :  1.  There  were  always 
more  inflammation  in  the  neighborhood  of  the  wound,  and  more  copious 
infiltration  of  the  parts,  than  in  a  subcutaneous  division  of  the  tendon 
in  the  same  rabbit ;  2.  Suppuration  frequently  occurred,  either  between 
the  retracted  ends  of  the  divided  tendon,  or  beneath  its  distal  end  ;  3. 
The  skin  was  more  apt  to  become  adherent  to  the  tendon,  and  so  to 
limit  and  hinder  its  sliding  movements,  when  the  healing  was  completed  ; 
4.  The  retracted  ends  of  the  tendon  were  more  often  displaced,  so  that 
their  axis  did  not  exactly  correspond  with  each  other,  or  with  that  of 
the  reparative  bond  of  union. 

Such  mishaps  were  often  observed  in  the  open  wounds,  but  were  rare 
after  the  subcutaneous  operations.  In  the  cases  of  open  wounds,  they 
were  avoided  as  often  as  the  wound  through  the  integuments  healed 
quickly  ;  and,  whenever  this  happened,  the  case  proceeded  like  one  in 
which  the  subcutaneous  division  had  been  made.  It  was  evident  that 
the  exposure  of  the  wounded  parts  to  the  air  did  little  harm,  if  it  was 
continued  for  only  a  few  hours  ;  a  fact  that  may  be  usefully  remem- 
bered when  operations  must  be  performed  on  tendons  which  it  is  not 
convenient  to  divide  unseen. 

These  same  cases  of  speedy  healing  of  the  opening  in  the  integuments 
served  to  show,  that  it  is  unimportant  for  the  healing  of  divided  Achil- 
les-tendons, whether  the  connective  tissue  sheath  or  covering  of  the  ten- 
don be  divided  or  not.  In  all  the  cases  of  open  division  in  these  ex- 
periments, it  was  completely  cut  through ;  yet,  when  the  external 
wound  healed  quickly,  the  union  of  the  divided  tendon  was  as  speedy 
and  as  complete  as  in  any  case  of  subcutaneous  division  in  which  it 
might  be  supposed  that  the  sheath  of  the  tendon  was  not  injured. 

I  will  describe  now  the  course  of  events  after  subcutaneous  division  of 
the  Achilles-tendon  ;  stating  only  what  was  generally  observed,  and  illus- 
trating it,  as  far  as  may  be,  with  the  annexed  diagram  (Fig.  25),  in 
which,  as  in  longitudinal  sections,  a  may  represent  the  natural  condi- 


192 


HEALING     OF    TENDONS. 


tion  of  the  tendon  and  its  muscles,  and  the  succeeding  figures  the  effects 
of  its  division  and  the  successive  stages  of  its  repair.* 

At  the  instant  of  the  division,  the  ends  of  the  tendon  separate  to  the 
distance  of  nearly  an  inch,  the  upper  portion  of  the  tendon  being  drawn 
up  the  leg  by  the  action  of  the  gastrocnemius  and  soleus  muscles  (b). 
The  retraction  is  comparatively  much  greater  than  is  usual  in  operations 
on  the  human  Achilles-tendon ;  for  where  these  are  done,  the  muscles 
are  seldom  capable  of  strong  or  extensive  contraction.  It  is  in  all 
cases  to  be  remembered  that  the  separation  is  effected  entirely  by  the 
withdrawal  of  the  upper  portion  of  the  tendon :  the  lower,  being  not 
connected  with  muscle.,  remains  with  its  end  opposite  the  wound.     To 


this  we  may  ascribe  the  general  fact  that  the  reparative  process  is  more 
active,  and  the  inflammatory  process  less  so,  at  the  upper  than  at  the 
lower  portion  of  the  tendon  :  for  the  latter  lies  in  the  very  centre  of  the 
chief  inflammatory  action  ;  while  the  former  is  removed  far  from  it, 
being  drawn  away,  at  once  from  the  seat  of  the  injury,  and  from  even 
the  slightest  exposure  to  the  air. 

I  have  already  said  that  very  little  blood  is  effused  in  the  subcu- 
taneous operations.  Commonly,  only  a  few  blotches  of  extravasation 
appear  in  and  near  the  space  from  which  the  upper  part  of  the  tendon 
is  retracted  (b).     The  first  apparent  consequence  of  the  division  of  the 


*  The  account  here  given  agrees  in  all  essential  respects  with  that  by  Lebert,  in  his  Ab- 
handlungen  .  .  .  der  prakt.  Chirurgie,  p.  403.  Neither  do  the  accounts  materially  differ, 
except  in  being  less  minute,  which  are  given  by  Von  Ammon  (De  Physiologia  Tenotomise), 
Duval  (Bull,  de  I'Acad.  Royale  de  Medecine,  1837),  and  Duparc  (Nederlandsch  Lancet, 
1837), 


HEALING    OF    TENDONS.  193 

tendon  is  the  effusion  of  a  fluid  or  semifluid  substance,  which,  like  the 
product  of  common  inflammation,  quickly  organizes  itself  into  the  well- 
known  forms  of  lymph-  or  exudation-cells.  These,  speedily  becoming 
more  distinctly  nucleated  and  elongated,  undergo  the  changes  which  I 
mentioned  in  describing  the  development  of  cells  in  granulations.  The 
exuded  lymph  makes  the  tissues  at  and  near  the  wound  succulent  and 
yellow,  like  parts  infiltrated  in  anasarca.  The  bloodvessels  near  the 
divided  tendon  enlarge,  as  in  an  inflamed  part,  and  appear  filled  with 
blood  (b,  c).  The  exudation,  together  with  the  enlargement  of  the  ves- 
sels, swells  the  parts,  so  that  the  skin  is  scarcely  at  all  depressed  be- 
tween the  separated  ends  of  the  tendon.  But  in  well-made  subcuta- 
neous sections,  this  inflammatory  product  is  of  small  amount,  and  takes, 
I  believe,  little  or  no  share  in  the  healing  of  the  injury ;  for  the  exuda- 
tion ceases  after  the  first  twenty-four  hours,  and  I  think  that  its  cells 
are  not  developed  beyond  the  state  in  which  they  appear  spindle-shaped. 
I  have  never  seen  indications  of  their  forming  filaments  of  connective 
tissue. 

In  rabbits,  forty-eight  hours  usually  elapse  before  there  are  distinct 
signs  of  the  production  of  the  proper  reparative  material.  This  is  de- 
posited in  the  fibro-cellular  tissue  that  lies  between  and  close  round  the 
separated  ends  of  the  tendon,  as  well  as  in  the  interspaces  of  the  ten- 
dinous fasciculi  of  those  ends.  It  thus  swells  up  the  space  between  the 
separated  ends,  and  makes  the  ends  themselves  larger,  and  somewhat 
ruddy,  soft,  and  succulent.  Some  portion,  at  least,  of  it  being  deposited 
where  the  inflammatory  effusion  was,  one  finds  their  constituents  mingled ; 
but  I  believe  that,  while  the  proper  reparative  material  develops  itself, 
the  product  of  the  inflammation  is  either  arrested  in  its  development, 
or  even  degenerates  ;  its  cells  shrivelling  and  gradually  wasting. 

I  need  not  now  describe  the  mode  of  development  of  the  reparative 
material  provided  for  divided  tendons  :  for  I  have  taken  it  as  a  typical 
example  of  the  development  of  lymph  into  nucleated  blastema,  and 
thence  into  fibrous  tissue  (p.  139).  To  the  naked  eye  it  appears  after 
three  days  as  a  soft,  moist,  and  grayish  substance,  with  a  slight  ruddy 
tinge,  accidentally  more  or  less  blotched  with  blood,  extending  from 
one  end  of  the  tendon  to  the  other,  having  no  well-marked  boundary^ 
and  merging  gradually  into  the  surrounding  parts  (c).  In  its  gradual 
progress,  the  reparative  material  becomes  commensurately  firmer^ 
tougher,  and  grayer,  the  ruddiness  successively  disappearing  from  the 
circumference  to  the  axis  ;  it  becomes,  also,  more  defined  from  the  sur- 
rounding parts,  and,  after  four  or  five  days,  forms  a  distinct  cord-like 
vascular  bond  of  connection  between  the  ends  of  the  tendon,  extend- 
ing through  all  the  space  from  which  they  have  been  retracted,  and  for 
a  short  distance  ensheathing  them  both  (d,  e). 

As  the  bond  of  connection  thus  acquires  toughness  and  definition,  so 
the  tissue  around  it  loses  its  infiltrated  and  vascular  appearance  :  the 
bloodvessels  regain  their  normal  size,  the  inflammatory  effusion  clears 


194  HEALING    OF    TENDONS. 

up,  and  the  integuments  become  looser,  and  slide  more  easily.  In 
every  experiment,  one  finds  cause  for  admiration  at  the  manner  in 
which  a  single  well-designed  and  cord-like  bond  of  union  is  thus  gradu- 
ally formed,  where  at  first  there  had  been  a  uniform  and  seemingly 
purposeless  infiltration  of  the  whole  space  left  by  the  retraction  of  the 
tendon. 

With  the  increase  of  toughness,  the  new  substance  acquires  a  more 
decidedly  filamentous  appearance  and  structure.  After  the  fourth  day, 
the  microscope  detects  nuclei  in  the  previously  homogeneous  fibrine-like 
reparative  material :  and  after  the  seventh  or  eighth  day  there  appear 
well-marked  filaments,  like  those  of  the  less  perfect  forms  of  fibrous 
tissue.  Gradually  perfecting  itself,  but  with  a  rate  of  progress  which 
becomes  gradually  less,*  the  new  tissue  may  become  at  last,  in  all  ap- 
pearance, identical  with  that  of  the  original  tendon.  So  it  has  happened 
in  the  valuable  specimens  presented  to  the  Museum  of  the  College  by 
Mr.  Tamplin.f  They  are  the  Achilles-tendon  and  the  tendons  of  the 
anterior  and  posterior  tibial  muscles  of  a  child  nine  months  old,  in  whom, 
when  it  was  five  months  old,  all  these  tendons  were  divided  for  the  cure 
of  congenital  varus.  The  child  had  perfect  use  of  its  feet  after  the 
operation,  and,  when  it  died,  no  trace  of  the  division  of  any  of  the  ten- 
dons could  be  discerned  even  with  microscopic  aid. 

In  the  instances  of  divided  human  tendons,  less  retraction,  I  have 
already  said,  takes  place  than  in  those  of  lower  animals.  The  con- 
necting bond  is  therefore  comparatively  shorter  ;  and  it  is  yet  more 
shortened  when,  like  a  scar,  it  contracts  as  it  becomes  firmer.  It  is 
impossible,  therefore,  to  say  what  length  of  new  material  was,  in  this 
case,  formed  into  exact  imitation  of  the  old  tendon.  But,  however  little 
it  may  have  been,  such  perfect  repair  as  these  specimens  show  is  ex- 
ceedingly rare.  More  commonly  the  difi'erences  between  the  Original 
tendon  and  the  new  substance  remain  well-marked.  The  latter  does 
not  acquire  the  uniform  arrangement  of  fibres,  or  the  peculiar  glisten- 
ing thence  accruing  to  the  normal  tendons  :  it  is  harder  and  less  pliant, 
though  not  tougher ;  its  fibres  appear  irregularly  interwoven  and  en- 
tangled, dull- white,  like  those  of  a  common  scar.  And  these  differences, 
though  as  time  passes  they  become  gradually  less,  are  always  seen  when 
a  longitudinal  section  is  made  from  behind,  through  both  the  ends  of 
the  tendon  and  the  new  substance  that  ensheaths  and  connects  them. 
In  such  a  section  (as  in  Fig.  25,  e),  one  sees  each  of  the  retracted  ends 
of  the  divided  tendon  preserving  nearly  all  its  peculiar  whiteness,  only 
somewhat  rounded  or  misshapen,  swollen,  and  imbedded  in  the  end  of 

*  One  may  remark  this  as  a  general  fact,  that  when  once  the  reparative  process  has  com- 
menced, much  more  appears  to  be  done  in  it  in  the  first  few  days  than  in  any  equal  subse- 
quent period  of  time.  It  may  be  another  instance  justifying  the  general  expression,  that 
production  is  easier  than  development  or  improvement,  and  that  the  earlier  or  lower  de- 
velopments require  less  organizing  force  than  the  higher  or  later. 

f  Nos.  358,  359,  360. 


HEALING    OF     MUSCLES.  195 

the  new  substance,  which  is  always  grayer,  or  less  glistening,  and  looks 
less  compact  and  regular.  In  the  retracted  ends  of  the  tendon,  one 
mav  discern  the  new  substance  mingled  with  the  old  and  interposed 
between  its  fasciculi,  with  which  one  may  believe  it  is  connected  by  the 
finest  dovetailing.* 

The  strength,  both  of  the  new  substance  itself  and  of  its  connection 
by  intermingling  with  the  original  substance,  is  worthy  of  remark.  To 
test  it,  I  removed  from  a  rabbit  an  Achilles-tendon,  -which  had  been 
divided  six  days  previously,  and  of  which  the  retracted  ends  were  con- 
nected by  a  bond  of  the  size  and  texture  usual  at  that  period  of  the 
reparative  process.  I  suspended  from  the  half-section  of  this  bond 
gradually  increased  weights.  At  length  it  bore  a  weight  of  ten  pounds, 
but  presently  gave  w^ay  with  it :  yet  we  may  suppose  the  whole  thick- 
ness of  the  bond  would  have  borne  twenty  pounds.  In  another  experi- 
ment, I  tried  the  strength  of  a  bond  of  connection  Avhich  had  been  ten 
days  forming :  this,  aftei>  bearing  suspended  weights  of  twenty,  thirty, 
forty,  and  fifty  pounds,  was  torn  with  fifty-six  pounds.  But  surely  the 
strength  it  showed  was  very  wonderful  when  we  remember  that  it  was 
not  more  than  two  lines  in  its  chief  diameter,  and  that  it  was  wholly 
formed  and  organized  in  ten  days,  in  the  leg  of  a  rabbit  scarcely  more 
than  a  pound  in  weight.  With  its  tenacity  it  had  acquired  much  of 
the  inextensibility  of  the  natural  tendon.  It  was  indeed  stretched  by 
the  heavy  weights  suspended  from  it,  yet  so  slightly  that  I  think  no 
exertion  of  which  the  rabbit  was  capable  would  have  sufficed  to  extend 
it  in  any  appreciable  degree. f  ' 

The  Healing  of  Muscles,  subcutaneously  divided,  presents  many  things 
exactly  similar  to  those  just  described  as  observed  in  the  healing  of 
tendons  similarly  divided,  and  the  structure  of  the  connecting  repara- 
tive bond  is  of  the  same  kind  ;  new  muscular  fibres,  I  believe,  are  never 
formed.  But,  in  the  experiments  which  I  made  on  the  triceps  extensor 
brachii,  and  the  tibialis  anticus  of  rabbits,  there  was  always  observed  a 
peculiar  inversion,  subsidence,  or  tucking  in  of  the  muscular  fibres  at 
the  divided  part ;  so  that  nearly  all  the  fasciculi  directed  their  cut  ends 
towards  the  subjacent  bone  or  fascia.  Thus  it  sometimes  appeared  to 
happen  that  though  the  retracted  portions  of  the  muscle  were  imper- 
fectly united,  yet  the  action  of  the  muscle  was  not  lost :  for  one  or  both  its 
ends,  acquiring  new  attachments  to  the  subjacent  parts,  could  still  act, 
though  with  diminished  range,  upon  the  joint  over  which  its  fibres  passed. 

*  The  appearances  are  shown  in  specimens  in  the  College  Museum,  Nos.  348  to  354 ; 
and  in  those  from  the  experiments  on  rabbits  in  the  Museum  of  St.  Bartholomew's. 

f  Reference  may  be  made  to  the  observations  of  Mr.  W.  Adams  "  On  the  Reparative 
Process  in  Human  Tendons  after  Division,"  London,  1860,  as  confirming  generally  what 
is  described  in  the  text.  In  this  work  an  abstract  of  the  various  opinions  entertained  by 
surgeons  on  the  process  of  reparation  of  these  structures  has  been  incorporated  in  the  form 
of  an  appendix. 


196  HEALING    OF    ARTERIES    AND    VEINS. 

In  general  it  appeared  that  the  reparative  material  was  less  quickly 
produced  than  after  division  of  the  tendons  ;  but  this  might  be  because 
of  the  greater  violence  inflicted  in  the  operation,  more  than  because  of 
the  structure  of  the  divided  parts.  The  usual  method  and  end  of  the  de- 
velopment of  the  reparative  material  were  the  same  as  after  division  of 
the  tendons ;  and  at  length,  but  always,  I  think,  more  slowly  than  with 
them,  the  ends  of  the  retracted  portions  became  inclosed  in  a  tough 
fibrous  bond  of  union. 

After  the  formation  of  this  bond,  the  healing  of  divided  muscles  is 
improved,  both  by  the  clearing  up  of  the  surrounding  tissues  infiltrated 
with  inflammatory  products,  and  by  the  contraction  of  the  new  bond, 
which  thus  draws  together  the  retracted  portions  of  the  muscle,  so  that 
they  may  nearly  coalesce.  Th.us,  in  a  man  who  had  cut  his  throat  long 
before  his  death,  and  had  divided  the  left  sterno-hyoid,  omo-hyoid,  and 
sterno-thyroid  muscles,  I  found  that  the  ends  of  these  muscles,  though 
they  must  at  first  have  retracted  considerably,  had  all  been  drawn  to 
attachments  on  the  cricoid  cartilage,  over  which  their  several  portions 
nearly  united. 

The  Healing  of  Injured  Arteries  and  Veins  is  commonly  a  more 
complicated  process  than  those  already  described,  on  account  of  the 
changes  that  ensue  in  the  blood  that  is  stagnant  within,  or  shed  around, 
the  injured  vessel.* 

Small  wounds  of  either  arteries  or  veins  may  heal  by  immediate  union, 
or  primary  adhesion,  as  those  of  any  other  tissue  may,  and  the  blood 
shed  into  the  adjacent  tissues  may  be  absorbed  as  from  common  ecchy- 
mosis.  An  artery  divided  in  only  part  of  its  circumference,  although 
it  may  be  for  a  time  contracted,  yet  does  not  remain  so  ;  neither  is  it 
commonly,  in  such  a  case,  obstructed  by  clot  within  its  canal.  Hence, 
after  such  wounds,  the  j)ulse  in  the  distal  or  lower  part  of  the  artery  is 
often  unaff'ected.  After  the  first  outrush  of  blood,  some  that  remains 
extravasated  among  the  tissues  usually  clots,  and  covers  the  wound  in 
the  artery ;  but  the  closure  is  often  ineff'ectual,  or  only  for  a  time,  and 
fresh  bleedings  ensue,  either  increasing  the  accumulation  of  extravasated 
blood,  or  pushing  out  the  clots  already  formed.  In  this  way,  with  re- 
peated hemorrhages  at  uncertain  intervals,  the  wound  in  an  artery  is 
often  kept  open,  and  at  the  end  of  two  or  three  weeks  may  show  no 
trace  of  healing,  but,  rather,  appear  widened  and  with  softened  everted 
edges.  In  such  a  case,  it  is  possible  that  the  wound  in  an  artery  may 
still  heal  by  granulations,  either  rising  from  its  edges  or  coalescing  over 
it  from  adjacent  parts  ;  but  the  event  is  too  unlikely  to  justify  the  wait- 
ing for  its  occurrence,  if  there  be  opportunity  for  surgical  interference. 

*  Nearly  all  that  follows  relates  to  the  healing  of  wounds  of  arteries.  The  process  in 
veins  appears  to  be  essentially  the  same,  but  more  quickly  accomplished.  See  Stilling: 
"Die  natUrlichen  Processe  bei  der  Heilung  durchschlimgener  Blutgefasse."'  Eisenach,  1834, 
p.  147  and  289. 


HEALING    OF    ARTERIES    AND    VEINS.  197 

In  the  case  of  an  artery  divided  quite  across,  three  chief  things  are 
to  be  considered  ;  namely,  the  natural  immediate  arrest  of  the  bleeding, 
the  closure  of  the  two  orifices,  and  the  disposal  of  the  blood  that  may 
become  stagnant  at  and  near  the  ends  of  the  divided  vessels. 

The  bleeding  is  arrested,  mainly,  by  the  contraction  of  the  muscular 
coat  of  the  artery.  Stimulated  by  the  injury  and  by  exposure  to  the 
air,  and  relieved  from  much  of  the  pressure  of  the  blood,  whose  onward 
course  is  less  resisted,  the  muscular  tissue  of  the  divided  artery  contracts 
and  closes,  or,  at  least,  diminishes,  the  canal.  In  some  instances  the 
contraction  is  narrowly  funnel-shaped  or  like  the  neck  of  a  Florence 
oil-flask,  and  the  end  of  the  artery  may  be  open,  while,  at  a  little  distance 
within,  its  canal  is  closed  or  much  narrower,  and  this  contracted  part  is 
filled  with  a  clot.  In  some,  the  exterior  layers  of  the  muscular  fibres 
seem  to  contract  rather  more  than  the  interior,  and  the  end  of  the  artery 
appears  prominent  or  pouting.  Many,  perhaps  trivial,  difi'erences  of 
this  kind  may  be  noticed  in  different  arteries  cut  across  in  amputations. 
Moreover,  the  processes  for  the  stoppage  of  bleeding  are  not  equally 
effective  in  the  upper  and  lower  ends  of  a  divided  artery,  for  whilst  the 
upper  end  may  be,  and  remain,  permanently  closed,  the  lower  end  may 
reopen,  and  bleeding  be  renewed  from  it,  some  time  after  the  wound 
has  been  inflicted. 

The  retraction  of  the  divided  artery  within  its  sheath,  or  among  the 
adjacent  tissues,  assists  to  stay  the  bleeding,  by  giving  opportunity  for 
the  blood  to  become  diffused,  as  it  flows  through  the  tissues  that  col- 
lapse over  the  end  of  the  artery  before  it  closes.  But  the  degree  to 
which  this  retraction  can  take  place  is  very  uncertain.  It  depends 
chiefly  on  the  laxity  or  the  closeness  of  the  attachment  of  the  artery  to 
the  surrounding  tissues,  and  on  the  extent  to  which  they  with  it  are 
divided,  and  with  it  are  capable  of  retraction.  In  amputations,  one  sees 
many  differences  in  these  respects.  Arteries  divided  close  to  ligament- 
ous parts  and  the  origins  of  muscles  appear  much  retracted,  because 
the  tissues  about  them  are  scarcely  at  all  drawn  back ;  so  it  is  in  am- 
putations just  below  the  knee  :  but  those  that  are  divided  where  there 
is  much  areolar  tissue,  or  where  muscles  are  far  from  their  origins,  as 
in  the  middle  or  lower  part  of  the  fore-arm,  appear  less  retracted,  be- 
cause these  surrounding  parts  are  retracted  as  much  or  more  than  they. 
In  like  manner,  arteries  from  which  branches  are  given  off  just  above 
the  place  of  division  retract  less  than  others,  the  branches  holding  them 
in  place. 

Equally  various  is  the  degree  in  which  the  bleeding  from  a  wounded 
artery  is  arrested  by  the  blood  collecting  around  it,  and  in  front  of  its 
orifice.  It  depends  mainly  on  the  degree  of  retraction  of  the  artery, 
and  on  the  facility  with  which  the  blood  can  escape  through  the  exter- 
nal wound.  It  is  assisted,  in  case  of  large  hemorrhage,  by  the  weaken- 
ing of  the  action  of  the  heart,  and,  perhaps,  by  the  readier  coagulation 
of  the  blood  which  ensues  in  syncope. 


198  HEALING    OF    ARTERIES    AND    VEINS. 

The  efficacy  of  these  means  for  the  arrest  of  bleeding  from  all  but  the 
principal  arterial  trunks  is  evident  enough  immediately  after  the  am- 
putation of  a  limb.  However  many  arteries  may  need  ligature,  they 
are  probably  not  more  than  a  tenth  of  those  that  were  just  now  traversed 
by  quick  streams  of  blood.  The  rest  are  already  closed  by  their  own 
muscular  action,  needing  no  assistance,  from  a  diminished  action  of  the 
heart,  or  the  effusion  of  blood  around  them. 

I  know  no  observations  showing  the  method  of  healing  and  permanent 
closure  of  the  small  arteries  that  thus  spontaneously  cease  to  bleed.  All 
the  accurate  inquiries  that  I  am  aware  of  relate  to  the  closure  of  the 
torn  umbilical  arteries,  which  have  hardly  a  parallel  in  other  vessels,  or 
else  to  the  more  complicated  cases  of  large  arteries  on  which  ligatures 
have  been  tied,  or  which  have  been  closed  by  some  artificial  means,  such 
as  the  "  Durchschlingung"  of  Stilling;  a  defect  much  to  be  regretted, 
since  the  ligature,  or  any  similar  means,  introduces  such  a  disturbance 
into  the  process  of  repair,  as  makes  it  a  morbid  process,  however  advan- 
tageous its  end  may  be.  Indeed,  when  a  divided  artery  is  tied,  the 
injury  to  be  repaired  is  not  that  of  the  wound,  but  that  of  the  ligature  ; 
an  injury  in  which  a  bruised  wound  dividing  the  middle  and  internal 
coats  of  the  artery,  a  bruise  with  continued  compression  of  its  external 
coat,  and  the  continued  presence  of  a  foreign  body,  are  superadded  to 
the  injuries  which  preceded  the  application  of  the  ligature. 

For  simplicity's  sake,  let  us  consider  the  repair  of  such  an  injury  in 
only  that  part  of  an  artery  which  is  above  the  ligature,  i.  e.,  nearer  to 
the  heart.  The  changes  in  the  part  beyond  the  ligature  are,  according 
to  Stilling,  the  same,  but  more  quickly  accomplished. 

Now,  in  this  repair,  three  parts  are  chiefly  concerned ;  namely,  (1) 
the  injured  walls  of  the  vessel  at  and  immediately  adjoining  the  liga- 
ture ;  (2)  the  part  of  the  vessel  between  the  ligature  and  the  first  branch 
above  it,  through  which  the  blood  can  flow  off;  and  (3)  the  blood  which, 
within  the  same  part  of  the  vessel,  i.  e.,  between  the  ligature  and  the 
first  branch  nearer  to  the  heart,  lies  nearly  stagnant.  The  healing  of 
the  artery  may  indeed  be  accomplished  without  the  help  of  this  blood, 
but  certain  changes  in  it  commonly  concur  with  the  rest  of  the  process. 

(1.)  The  injured  walls  of  the  vessel,  and  the  tissue  immediately  around 
them,  inflame,  and  exudation  of  lymph  takes  place  in  them  especially  at 
and  just  above  the  divided  parts  of  the  coats  constricted  and  held  in 
contact  by  the  ligature.  Thus,  as  by  primary  adhesion,  or  by  an  ad- 
hesive inflammation,  the  wound  made  by  the  ligature  in  the  middle  and 
internal  coats  is  united ;  and,  through  the  same  process,  this  union  is 
strengthened  by  the  adhesion  of  these  coats  to  the  outer  coat,  and  of  the 
outer  coat  to  the  sheath  or  other  immediately  adjacent  tissues.  There 
i  s  a  general  adhesion  of  these  parts  to  one  another ;  they  appear  thick- 
ened, infiltrated,  and  morbidly  adherent:  beneficial  as  the  result  is,  it 
is  the  result  of  disease.  Through  the  same  disease,  the  portion  of  the 
outer  coat  yf  the  artery  included  within   the   ligature  sloughs  and  is 


HEALING    OF    ARTERIES    AND    VEINS.  199 

brought  away,*  or  it  ulcerates,  and  permits  the  reraoval  of  the  ligature, 
and  a  more  natural  process  of  organization  of  the  inflammatory  products 
among  which  it  lay,  and  which  its  presence  had  tended  to  increase. 

(2.)  When  any  part  of  an  artery,  through  any  cause,  ceases  to  be 
traversed  by  blood,  its  walls  tend  to  contract  and  close  its  canal.  The 
application  of  a  ligature  brings  into  this  condition  all  that  part  of  the 
tied  artery  which  lies  between  it  and  some  branch  or  branches  higher 
up,  through  which  the  stream  of  blood  may  be  carried  off.  The  walls 
of  this  part  therefore  slowly  contract,  gradually  reducing  the  size  of 
its  canal,  and,  in  some  instances,  probably  closing  it.  Mr.  Guthrief 
has  particularly  noticed  after  the  application  of  ligatures,  the  curling 
inwards  of  the  divided  inner  and  middle  coats,  which  thus  in  a  measure 
recede  from  the  contact  or  proximity  of  the  ligature.  There  is  not  in 
this,  as  in  the  last  described  part  of  the  process,  any  disease  :  the  con- 
traction is  only  the  same  as  that  of  the  ductus  arteriosus,  the  umbilical 
arteries,  and  other  vessels,  from  Avhich,  in  normal  life,  the  streams  of 
blood  are  diverted  ;  and  the  closure  may,  as  in  them,  according  to  Ro- 
kitansky,!  be  assisted  by  deposit  from  the  blood  thickening  with  an 
opaque  white  layer  the  internal  coat.  The  time  occupied  by  this  con- 
traction, and  its  extent  in  length  along  the  artery,  are  too  various  to 
be  stated  generally.  When  it  is  permanent,  the  coats  of  the  artery,  at 
its  completion,  waste,  lose  their  peculiar  structures,  and  are  slowly 
transformed  into  a  fibrous  tissue,  such  as  that  which  composes  the  solid 
cord  of  the  ductus  arteriosus. 

(3.)  Respecting  these  two  consequences  of  the  application  of  liga- 
tures, little  difference  of  opinion  can  exist ;  and  it  may  be  repeated,  that 
either  of  these  may  suffice  for  the  safe  closure  of  the  artery.  Thus,  on 
the  one  hand,  we  sometimes  see  an  artery  pervious  to  the  very  end  of 
a  stump,  but  there  safely  closed  at  the  seat  of  ligature ;  and  on  the 
other,  the  naturally  torn  umbilical  arteries  of  animals,  and,  I  suspect, 
the  arteries  which  in  common  wounds  are  divided  and  spontaneously 
cease  to  bleed,  are  closed  and  obliterated  without  inflammation.  How- 
ever, much  more  commonly,  the  blood  contained  in  and  near  the  end 
of  the  tied  artery  becoming  stagnant,  concurs,  with  both  the  processes 
just  described,  to  the  closure  of  the  canal. 

Concerning  this  third  constituent  of  the  process,  more  questions  have 
been  raised.  I  shall  describe  it  from  the  admirable  observations  of 
Stilling§  and  Zwicky.||  They  were  made  in  a  large  series  of  experi- 
ments on  the  arteries  of  animals :  those  of  Stilling  refer  chiefly  to  the 
changes  visible  to  the  naked  eye,  those  of  Zwicky  to  the  more  minute. 

When  an  artery  is  tied,  the  blood,  as  already  said,  becomes  nearly 

*  See  a  specimen  from  a  tied  subclavian  artery  in  the  Museum  of  St.  Bartholomew's. 

f  Commentaries  on  the  Surgery  of  the  War,  1853. 

%  Pathologische  Anatomie,  B.  ii,  p.  623. 

§  Die  natiirl.  Processe  bei  der  Heilung  durchschlnngener  Blutgefasse.     Eisenach,  1S34. 

II  Die  Metamorphose  des  Thrombus.     Zurich.  1845. 


200  HEALING    OF    ARTERIES    AND    VEINS. 

stagnant  in  the  canal,  from  the  ligature  upwards  to  the  first  principal 
branch.  In  an  uncertain  time,  varying  from  one  to  eighteen  hours,  a 
part  of  this  blood  coagulates ;  and  the  clot  commonly  assumes  a  more 
or  less  conical  form.  The  base  of  this  "  conical  clot,"  "  internal  ob- 
turator," "  plug,"  or  "  thrombus,"  rests  in  and  fills  the  end  of  the  ar- 
tery, at  the  wound  made  by  the  ligature ;  its  apex  usually  lies  nearly 
opposite  the  first  branch  above,  in  the  axis  of  the  artery :  it  is  sur- 
rounded by  fluid,  but  still  nearly  stagnant,  blood,  which,  except  at  its 
base,  intervenes  between  it  and  the  internal  surface  of  the  artery.  At 
its  base,  and  higher  up  if  it  fills  the  artery,  the  clot  is  dark  and  soft, 
like  a  common  blood-clot ;  its  upper  part  and  apex  are  denser,  harder, 
and  whitish,  like  coagulated  fibrine ;  and  layers  of  white  substance  are 
often  gradually  superadded  to  its  middle  and  apex,  and  increase  its 
adhesion  to  the  walls  of  the  vessel. 

In  course  of  time,  the  clot  becomes  marked  with  paler  spots,  and 
then  porous,  spongy,  and  cavernous,  as  if  it  were  being  gradually  chan- 
nelled from  its  surface  towards  its  central  parts.  In  this  state,  in- 
jection impelled  into  the  artery  will  enter  and  distribute  itself  in  the 
clot,  making  it  appear  vascular,  or  like  a  cavernous  tissue.*  While 
thus  changing,  also,  it  becomes  gradually  more  decolorized,  passing 
through  ruddy,  rosy,  and  yellowish  tints,  till  it  is  nearly  colorless.  As 
it  loses  color  it  gains  firmness,  and  its  base  and  the  greater  part  of  its 
length  become  more  firmly  adherent  to  the  inner  surface  of  the  artery, 
directly  or  through  the  medium  of  the  Ij^mph  deposited  on  it.  In  this 
increasing  firmness,  the  clot,  moreover,  is  acquiring  a  more  definitely 
fibrous  texture  ;  and,  as  the  same  change  is  gradually  ensuing  in  the 
inflammatory  products  deposited  near  the  ligature,  the  clot  and  they 
unite  more  firmly  than  before.  The  walls  of  the  artery,  also,  gradually 
closing  in  on  the  clot,  unite  with  it ;  and,  finally,  as  they  also  lose  their 
peculiar  texture,  and  become  fibrous,  the  clot,  and  they,  together,  form 
the  solid  fibrous  cord  by  which  the  tied  portion  of  the  artery  is  replaced; 
a  cord  which  commonly  extends,  as  did  the  clot,  from  the  seat  of  the 
ligature  to  the  first  principal  branch  above  it. 

The  minuter  changes  in  the  clot,  associated  with  those  visible  to  the 
naked  eye,  are,  chiefly,  that  it  acquires  a  fibrous  or  fibro-cellular  tex- 
ture, and  becomes  vascular.  I  have  already  said  (p.  135),  that  Zwicky 
has  traced  the  development  of  the  fibrine  of  the  clot  into  fibrous  tissue 
through  the  formation  of  nucleated  blastema ;  and,  probably,  I  need 
not  add  to  the  descriptions  of  this  process  already  drawn  from  other 
though  similar  instances  of  it  (pages  143  and  193).  The  development, 
or,  at  least,  the  later  part  of  it,  is  accomplished  much  more  slowly  than 

*  It  was  such  an  injection,  probably,  that  half  deceived  Hunter  into  the  behef  that  he 
had  found  the  beginning  formation  of  new  bloodvessels  in  the  clot  (Works,  vol.  iii,  p.  119  ; 
and  Museum  of  the  College,  No.  11);  and  such  led  Stilling  into  one  of  the  few  errors  in  his 
essay,  inducing  him  to  believe  that  the  clot  thus  became  vascular  independently  of  the  ves- 
sels of  the  surrounding  parts. 


HEALING    OF    DIVIDED    NERVES.  201 

in  the  reparative  material  of  tendons  in  rabbits ;  needing  more  than 
ten  weeks  in  the  clots  formed  in  dogs,  and  more  than  two  years  in  those 
in  men.  The  retardation  may  depend  in  some  measure  on  the  presence 
of  the  blood-corpuscles  in  the  clot ;  for  these,  though  they  seem  not  to 
affect,  or  take  part  in,  the  development  of  the  fibrine,  yet  probably,  as 
they  suffer  degeneration  preparatory  to  removal,  may  retard  it.* 

The  bloodvessels  usually  enter  the  organizing  clot,  in  dogs,  in  the 
fourth  week,  when  already  it  has  acquired  a  nucleated  and  imperfectly 
fibrous  tissue,  and  firmness  in  the  place  of  the  spongy  texture  from 
which  it  had  derived  a  spurious  appearance  of  vascularity.  They  pass 
into  it,  apparently,  from  the  vessels  formed  in  the  lymph  exuded  within 
the  artery,  in  and  just  above  the  situation  of  the  ligature  ;  hence  they 
enter  its  lower  part,  and  gradually  extend  towards  its  apex. 

Such  is  the  important  process  for  the  healing  of  tied  arteries.  In  ap- 
plying the  description  drawn  from  experiments  on  animals  to  the  cases 
of  human  arteries,  the  same  allowance  must  be  made  as  in  the  repairs  of 
fractures  and  of  divided  tendons.  The  process  is  less  Sipeedy,  less  sim- 
ple, less  straightforward  (if  I  may  so  speak),  more  prone  to  deviate  and 
to  fail,  through  excess  of  that  disease,  by  a  measured  amount  of  which 
the  security  of  the  artery  is  achieved. f 

The  Sealing  of  Divided  Nerves  may  be  accomplished  in  two  methods, 
which  may  be  named,  respectively,  primary  and  secondary  union,  and 
may,  probably,  be  compared  with  the  processes  of  primary  adhesion 
(p.  149),  and  of  connection  by  intermediate  new-formed  bonds  (p.  191). 

I  know  no  instances  in  which  nerves  healed  in  the  first  method  have 
been  examined,  but  the  nature  of  the  process  may  be  explained  by  the 
history  of  a  case  in  which  it  occurred  : 

A  boy,  eleven  years  old,  was  admitted  into  Saint  Bartholomew's 
Hospital,  under  Mr.  Stanley,  with  a  wound  across  the  wrist.  This 
wound,  which  had  been  just  previously  made  with  a  circular  saw,  ex- 
tended from  one  margin  to  the  other  of  the  forearm,  about  an  inch  above 
the  wrist-joint.  It  went  through  all  the  flexor  tendons  of  the  fingers 
and  thumb,  dividing  the  radial  artery  and  nerve,  the  median  nerve  and 
artery,  and  extending  for  a  short  distance  into  the  radius  itself.  The 
ulnar  nerve  and  artery  were  not  injured ;  the  condition  of  the  inter- 
osseous artery  was  uncertain,  but  the  interosseous  ligament  was  exposed 
at  the  bottom  of  the  wound.  Half  an  inch  of  the  upper  portion  of  the 
divided  median  nerve  lay  exposed  in  the  wound,  and  was  distinctly  ob- 

*  The  changes  ensuing  in  the  blood-corpuscles  are  described  by  Zwicky;  but  I  omit  them, 
since  they  take  no  evident  part  in  the  reparative  process,  and  are,  as  yet,  not  clearly  ascer. 
tained. 

f  Rokitansky  (b,  ii,  p.  616)  may  be  referred  to  concerning  some  events  in  the  process 
which  are  not  yet  clearly  ascertained;  such  as  the  amount  to  vv'hich,  in  some  cases,  the  clot 
may  be  absorbed,  and  the  share  taken  by  deposit  from  the  blood  producing  opaque  vi^hite 
thickening  of  the  inner  coat  of  the  artery. 

14 


202  healhs^g   of  divided  nerves. 

served  and  touched  by  Mr.  Stanley,  myself,  and  others.  All  sensation 
in  the  parts  supplied  from  the  radial  and  median  nerves  below  the  wound 
was  completely  lost  directly,  and  for  some  days  after  the  injury. 

The  radial  artery  was  tied,  and  the  edges  of  the  wounded  integuments 
put  together.  No  particular  pains  were  taken  to  hold  the  ends  of  the 
divided  median  nerve  in  contact,  but  the  arm  was  kept  at  rest  with  the 
wrist  bent. 

After  ten  days  or  a  fortnight  the  boy  began  to  observe  signs  of  re- 
turning sensation  in  the  parts  supplied  by  the  median  nerve,  and  these 
increasing,  I  found,  a  month  after  the  wound,  that  the  nerve  had  nearly 
recovered  its  conducting  power.  When  he  was  blindfolded,  he  could 
distinctly  discern  the  contact  of  the  point  of  a  pencil  with  his  second 
finger,  and  the  radial  side  of  his  third  finger ;  he  was  less  sure  when 
his  thumb  or  his  forefinger  was  touched,  for  though  generally  right,  he 
sometimes  thought  one  of  these  was  touched  when  the  contact  was  with 
the  other ;  and  there  were  a  few  and  distant  small  portions  of  the  skin 
supplied  by  the  median  nerve  from  which  he  still  derived  no  sensation 
at  all. 

Now  all  this  proves  that  the  ends  of  the  divided  median  nerve  had 
coalesced  by  immediate  union,  or  by  primary  adhesion  with  an  exceed- 
ingly small  amount  of  new  substance  formed  between  them.  In  the 
ordinary  secondary  healing  of  divided  human  nerves,  twelve  months 
generally  elapse  before,  if  ever,  any  restoration  of  the  function  is  ob- 
served ;  in  this  case,  the  nerve  could  conduct  in  a  fortnight,  and  per- 
haps much  less,  after  the  wound.  The  imperfection  of  its  recovery  is 
just  what  one  might  expect  in  such  a  mode  of  union.  One  might  antici- 
pate that  some  of  the  fibres  in  one  of  its  portions  would  fail  to  be  united 
to  any  in  the  other  portion :  and  the  parts  supplied  by  these  filaments 
would  necessarily  remain  insensible.  So,  again,  one  might  expect  that 
some  of  the  fibres  in  one  portion  would  unite  with  some  in  the  other, 
with  which  they  were  not  before  continuous,  and  which  supplied  parts 
alien  from  those  to  which  themselves  were  destined ;  in  all  such  disloca- 
tions of  filaments  there  would  be  confused  or  transferred  sensations. 
But,  among  all  the  fibres,  some  would  again  combine  in  the  same  con- 
tinuit}^  in  which  they  had  naturally  existed  ;  and  in  these  cases  the 
function  would  be  at  once  fully  restored.* 

*  I  saw  this  boy  again  nearly  a  year  after  the  injury.  He  had  ahnost  perfect  sensation 
in  all  the  distribution  of  the  median  nerve,  except  in  the  last  phalanges  of  the  thumb  and 
fore-finger.  These  had  not  decreased  or  changed  in  texture;  but  they  were  very  liable  to 
become  cold,  and  he  came  to  the  hospital  because  large  blisters  had  formed  on  them.  He 
had  been  warming  his  hands  at  an  open  fire,  and  the  heat,  which  was  not  uncomfortable  to 
the  rest  of  the  hands,  had  blistered  these  parts,  as  boiling  water  would  have  blistered  healthy 
ones.  He  had  almost  completely  recovered  the  movement  of  his  fingers.  SchifF  in  his 
Physiology  (p.  123),  remarking  on  this  and  the  case  immediately  following,  states  that  the 
rapid  union  and  recovery  of  sensation  observed  in  them  corresponds  with  what  he  has 
so  frequently  found  in  the  warm-blooded  animals  on  which  he  has  experimented  He  as- 
cribes the  quick  recovery  to  the  wound   being   made  with   a  sharp  cutting  instrument,  and 


HEALING    OF    DIVIDED     NERVES.  203 

While  this  case  was  under  observation,  Mr.  Gatty  sent  me,  with  the 
permission  of  Mr.  Heygate,  In  Avhose  practice  the  case  occurred,  the 
following  particulars  of  a  similar  Instance  of  repair  : 

A  lad,  near  Market  Harborough,  thirteen  years  old,  had  his  hand 
nearly  cut  off  at  the  wrist-joint  by  the  knife  of  a  chaff-cutting  machine. 
The  knife  passed  through  the  joint,  separating  a  small  portion  of  the 
ends  of  the  radius  and  of  the  ulna,  and  leaving  the  hand  attached  to 
the  fore-arm  by  only  a  portion  of  integument  about  an  inch  wide,  con- 
nected with  which  were  the  ulnar  vessels  and  nerve,  and  the  flexor 
carpi  ulnaris  muscle — all  uninjured.  The  radial  artery  and  some  small 
branches  being  tied,  the  hand  and  arm  were  brought  into  apposition, 
and  after  removing  a  small  portion  of  extensor  tendon  that  protruded, 
were  retained  firmly  with  adhesive  plaster  and  a  splint  of  pasteboard. 
The  wound  went  on  very  well,  and  was  left  undisturbed  for  a  week. 
The  warmth  of  the  hand  returned  ;  in  ten  or  twelve  days  after  the  In- 
jury there  was  slight  sensation  in  the  fingers,  but  in  the  thumb  none 
was  discernible  till  more  than  a  fortnight  had  elapsed. 

Finally,  the  sensation  of  the  hand  and  fingers,  and  most  of  their 
movements,  were  perfectly  restored. 

In  this  case,  again,  it  seems  impossible  to  explain  the  speedy  resto- 
ration of  the  conducting  power  of  the  nerve,  except  on  the  supposition 
that  its  divided  fibres  had  immediately  reunited.  We  have  no  evidence 
that  new  nerve-fibres  could  in  so  short  a  time  be  formed :  all  the  cases 
of  less  favorable  healing  show  that  they  require  a  year  or  more  for  their 
formation. 

I  need  hardly  add  the  practical  rule  we  may  draw  from  these  cases. 
It  is,  briefly,  that  we  may,  with  good  hope  of  great  advantage,  always 
endeavor  to  bring  into  contact,  and  immediately  unite,  the  ends  of  di- 
vided nerves  ;  and  that  we  need  not  in  all  such  cases  anticipate  a  long- 
continued  suspension  of  the  sensation  and  other  functions  of  the  part 
the  nerves  supplied. 

The  secondary  healing  of  divided  nerves  presents  many  features  simi- 
lar to  that  of  divided  tendons.  A  bond  of  new  substance  is  formed, 
which  connects  the  ends  of  the  retracted  portions  of  the  nerve,  and  in^ 
which,  though  at  first  it  is  like  common  reparative  material,  new  nerve- 
fibres  form,  and  connect  themselves  with  the  fibres  in  the  portions  above- 
and  below.  I  need  not  dwell  on  the  formation  or  development  of  this- 
connecting  bond:  the  subject  is  amply  treated  in  several  works  on  phy- 
siology ;*  and  it  is  thoroughly  illustrated,  so  far  as  the  appearances  to 
the  naked   eye  are  concerned,  by  the  valuable  series  of  preparations 

states  that  such  wounds,  when  unaccompanied  by  loss  of  substance,  heal  within  a  few  days. 
Moreover,  he  considers  that,  next  to  the  connective  tissue,  nerves,  when  cleanly  divided,  heal 
more  readily  than  any  other  texture,  surpassing  in  this  respect  even  the  bones.  On  the  other 
hand,  if  the  nerve  be  greatly  injured  previous  to,  or  during,  the  section,  as  by  pinching  it 
with  the  forceps,  &c.,  then  the  process  of  restoration  takes  a  much  longer  time. 

*  See  especially  Miiller's  Physiology,  by  Baly,  i,  p.  457  ;  Valentin's  Physiologie,  i,  p. 
702;  Hildebrandt's  Anatomie,  i,  p.  291  ;  SchifFs  Physiologie,  i,  1859. 


204  HEALING    OF    DIVIDED     NERVES. 

given  to  the  Museum  of  the  College  by  Mr.  Swan.*  Dr.  Waller,f  by 
watching  the  process  which  follows  the  division  of  the  glosso-pharyn- 
geal  nerve  in  frogs,  has  concluded  that,  after  a  nerve  is  divided,  the 
old  fibres  in  the  distal  portion  never  recover  their  functions.  They 
degenerate,  and  new  fibres  gradually  form  in  the  whole  length  of  the 
nerve  from  the  place  of  division  to  the  peripheral  distribution.  These 
new  fibres  connect  themselves  with  those  in  the  connecting  bond  of  re- 
pair, and  through  these  with  the  old  fibres  in  the  proximal  portion  of 
the  nerve. I 

The  repair  of  nervous  centres  has  been  comparatively  little  studied. 
Flourens  has  indeed  shown§  that  deep  wounds,  both  of  the  brain  and 
spinal  cord,  unite,  and  that  a  restoration  of  function  occurs.  The 
experiments  of  M.  Brown-Sequard||  have  proved  that,  after  complete 
division  of  the  mid-dorsal  part  of  the  spinal  cord  of  pigeons,  and  after 
division  of  more  than  half  of  that  of  guinea-pigs,  the  sensibility  and 
movements  of  the  hinder  part  of  the  body  may  be  almost  completely 
restored  in  about  twelve  months  ;  and  that  the  substance  by  which  the 
injury  of  the  cord  is  healed  contains,  with  connective  tissue,  abundant 
well-formed  nerve-fibres  connected  with  those  of  the  cord  above  and 
below,  and  sparing  nerve-cells. 

Schrader's  experiments  of  dividing  and  removing  small  portions  of 
the  cervical  ganglia,  and  the  ganglion  of  the  vagus,  of  rabbits,  found 
union  by  fibrous  bonds,  but  no  regeneration  of  ganglion- cells,  after 
eleven  weeks. T[  Valentin's  similar  experiments  had  scarcely  a  more 
positive  result.** 

*  Nos.  2169  to  2175.  All  these  specimens,  and  the  appearances  of  the  formation  of  new 
nerve-fibres  which  they  display,  are  described  and  illustrated  by  Mr.  Swan,  in  his  "Trea- 
tise on  the  Diseases  and  Injuries  of  Nerves."  In  Nos.  2165  to  2168  in  the  College  Museum, 
Mr.  Hunter  has  shown  the  formation  of  the  bulb  at  the  ends  of  divided  nerves,  and  the  ex- 
tension of  nerve-fibres  into  it. 

■f  London  Journal  of  Medicine,  July,  1852. 

J  Some  recent  investigations  would  appear  to  indicate  that  so  complete  a  disappearance 
of  the  fibres  of  the  distal  part  of  the  divided  nerve  hardly  takes  place,  as  Waller  had  sup- 
posed. From  these  it  seems  probable,  that  whilst  many  of  the  nerve-fibres  lose  their  con- 
tents after  division,  the  neurilemma  remains,  and  the  regenerative  process  fills  it  with  the 
normal  contents.  (See  Bruch,  Schiff,  and  Lent,  in  KoUiker's  Manual  of  Mic.  Anat.  1860.) 
Hjelt  (Virchow's  Archiv,  vol.  xix,  1860)  believes  that  the  union  of  these  refilled  nerves  with 
the  proximal  ends  of  the  divided  fibres  takes  place  through  an  increased  growth  of  the  nu- 
clei of  the  neurilemma  and  the  interstitial  connective  substance  between  the  divided  ends. 
Changes  subsequently  take  place  in  these  nuclei  and  the  interstitial  connective  substance 
which  result  in  the  formation  of  new  nerve-fibres,  which  serve  as  a  bond  of  connection  be- 
tween the- two  ends. 

^  Recherches  exper.  sur  les  syst.  nerv. 

II  Comptes  Rendus  de  la  Soc.  de  Biologie,  t.  i,  p.  17 ;  t.  ii,  p.  3 ;  t.  iii,  p.  77. 

^  Experimenta  circa  Regenerationem  in  Gangliis  nerveis.     Gottingen,  1850. 

**  Physiologic,  i,  703.  Walter  has  anew  investigated  this  subject  (De  regeneratione  gan- 
gliorum,  Bonn.  1853),  but  his  results  are  mostly  negative.  In  one  case,  however,  he  saw, 
after  excision  of  the  second  ganglion  of  the  vagus,  in  the  upper  part  of  the  new-formed  swell- 
ing, many  normal  ganglion-cells.     He  could  not  satisfy  himself  that  there  was  any  restora- 


^  HEALING    OF    SKIN.  205 

After  wounds  and  losses  of  substance  of  the  brain,  a  large  quantity 
of  new  material  may  be  formed  to  fill  up  the  gap  ;*  but  observations 
are  wanting  to  show  how  much  this  may  contain  of  proper  cerebral  sub- 
stance. I  have  found  nerve-fibres  in  it  after  thirty-three  years  (see  p. 
76) ;  but  in  the  same  specimen  there  was  no  appearance  of  gray  matter. f 

The  last  tissue  to  the  healing  of  which  I  shall  particularly  refer,  is 
the  skin.  I  need  not  indeed  describe  the  whole  process,  because  nearly 
all  that  was  said  of  the  healing  processes  generally  was  chiefly  illustrated 
by  instances  of  wounds  involving  the  skin.  Yet  it  may  be  useful  to 
indicate  the  skin  as,  on  the  whole,  the  part  which,  being  most  exposed 
to  injury,  is  capable  of  the  best  repair ;  that  which  heals  most  com- 
monly by  the  immediate  union,  most  quickly  by  primary  adhesion  ;  that 
which  produces  the  most  rapidly  and  securely  organizing  granulations. 
The  healing  of  skin  is  further  favored  by  its  extensibility  and  loose 
connection  with  adjacent  parts  ;  so  that,  when  large  surfaces  are  to  be 
healed,  the  contracting  granulations  can  draw  over  their  borders  the 
loose  skin  around.  Moreover,  the  new-formed  skin  imitates  the  old 
skin  very  well,  if  we  consider  the  complexity  of  its  structure.  I  am  not 
aware  that  the  smooth  muscular  fibres,  or  any  of  the  granular  struc- 
tures of  the  skin,  or  hair  follicles,  are  formed  in  its  scars  ;  but  its  white 
fibrous  and  elastic  tissues,  its  connective  tissue  corpuscles,|  its  papillae 
and  epidermis,  are  all  well  formed  in  them. 

The  new  cuticle  grows  chiefly  from  the  margin  of  the  wound  centri- 
petally  over  the  surface ;  but  it  may  arise,  in  the  midst  of  a  raw  sur- 
face, on  granulations,  independently  of  any  pre-existing  cuticular  struc- 
tures from  which  it  might  be  derived.  The  new  epidermal  cells,  as  C. 
0.  Weber's  observations!  would  show,  are  formed  by  a  conversion  of 
the  connective-tissue  corpuscles  of  the  superficial  layer  of  granulation- 
cells,  which  lose  their  spindle-like  and  assume  a  polygonal  shape.  It 
is  commonly  said  that  the  smoothness  of  a  scar  is  due  to  the  absence 
of  papillae,  but  I  believe  it  depends  only  on  the  tightness  of  the  new- 
formed  skin  and  its  want  of  such  wrinkled  and  furrowed  lines  as  natu- 
rally exist.  If  a  thin  section  be  made  of  the  border  of  a  healing  wound, 
so  as  to  include  the  new-formed  layer  of  epidermis,  the  granulations 

tion  of  function.  Schiff  again  thinks  that  the  second  ganglion  of  the  vagus  is  not  so  pre- 
cisely bounded  that  it  could  with  certainty  be  said  that  excision  of  the  swelling  had  re- 
moved all  the  ganglion-cells,  and  that^  therefore,  those  found  by  Walter  may  not  have  been 
new-formed  cells. 

*  See  especially  Arnemann  :  Versuche  iiber  das  Gehirn  und  Riickenmark.  Gottingen, 
1787. 

f  Cases  are  recorded  by  Viruhow  (Gesam.  Abhand.  p.  99S)  and  Tiingel  (Virchow's 
Archiv,  B.  xvi,  p.  166),  in  which  nodules  of  gray  cerebral  substance  are  stated  to  have  been 
found  in  parts  of  the  brain  in  which  no  such  masses  should  have  been  present.  But  there 
is  no  evidence  that  these  formations  were  occasioned  by  any  previous  injury  to  the  parts. 

X  Billroth,  Beitrage  zur  Path.  Hist.  1858,  Berlin. 

§  Entwicklung  des  Eiters,  &c.      Virchow"s  Archiv,  B.  xv. 


206 


HEALING    OF    SKIN. 


Fig.  26. 


now  skinned  over  will  be  found,  as  in  the  annexed  diagram  (Fig.  26), 
presenting  the  papillary  form.     They  consist  still  of  nucleated  cells,  but 

the  shape  of  papillae  is  acquired,  or  rather, 
is  retained ;  for  the  likeness  of  a  granu- 
lating surface  to  a  finely  papillary  one  is 
evident,  and  may  be  regarded  as  an  ex- 
ample of  the  general  tendency  of  new- 
formed  structures,  even' in  disease,  to 
assume  a  plan  of  construction  similar  to 
that  of  the  adjacent  parts.  The  likeness 
extends  to  the  arrangement  of  the  blood- 
vessels ;  and  the  papillary  structure  is  not 
lost  in  the  later  development  of  the  scar.  If  the  epidermis  of  a  scar 
be  separated,  its  under  surface  will  present  a  series  of  depressions  cor- 
responding with  the  elevations  of  the  papillse  on  which  it  was  adapted. 
The  subjoined  sketch  represents  the  under  surface  of  epidermis  so  re- 
flected from  a  scar  on  the  arm  of  a  negro :  and  may  illustrate  not  only 
the  plan  of  the  papillse,  of  which  it  was  like  a  mould,  but,  by  its  color, 
the  complete  reproduction  of  a  rete  nigrum.* 

In  concluding  the  lectures  on  Repair,  and  before  beginning  those  on 
Inflammation,  let  me  briefly  state  the  rela- 
.tions  of  the  one  process  to  the  other. 

It  is  not  because  we  have  any  well-defined 
idea  of  inflammation  that  it  is  desirable  to 
refer  to  it,  as  if  it  were  a  standard  with 
which  we  might  compare  other  organic  pro- 
cesses ;  but  such  a  reference  seems  neces- 
sary, because  some  idea  of  inflammation 
mingles  itself  with  nearly  everything  that  is 
considered  in  surgical  pathology.  Nowhere 
is  this  more  manifest  than  in  what  has  been 
written  in  surgical  works  upon  the  methods 
of  repair ;  concerning  which  a  general  im- 
pression seems  still  to  be,  that  a  process  of 
inflammation  forms  part  of  the  organic  acts 
by  which  even  the  smallest  instance  of  repair  is  accomplished. 


Fig.  27. 


*  For  the  farther  study  of  the  healing  process,  esj^ecially  in  the  tissues  and  organs  not 
mentioned  in  this  lecture,  I  must  refer  the  reader  either  to  special  treatises  on  the  pathology 
of  those  parts,  or  to  the  chief  works  on  General  Anatomy,  especially,  in  relation  to  all  but 
microscopic  observations,  to  that  of  Hildebrandt,  edited  byE.  H.Weber;  and  to  the  chapters 
on  Reproduction  in  Miiller's  Physiology,  by  Baly,  vol.  i,  p.  440,  and  in  Valentin's  Physio- 
logie,  i,  700.  The  power  of  repair  in  the  cornea  is  illustrated  especially  by  Dr.  Bigger,  in 
the  Dublin  Journal  of  Med.  Science,  1837;  and  by  Donders,  in  the  Onderzoekingen  .  .  .  . 
der  Utrechtsche  Hoogeschool,  D.  i,  p.  3] .  The  repair  of  fractured  teeth  by  bone  is  de^ 
scribed  by  Mr.  Tomes  in  his  "  Dental  Surgery."  The  Museum  of  the  College  has  the  best 
specimens,  illustrating  repair,  that  I  am  acquainted  with. 


I 


RELATIONS    OF    REPAIR    AND    INFLAMMATION.  207 

Now,  the  processes  we  have  traced  appear  to  warrant  these  general 
conclusions : 

1.  In  the  healing  of  a  wound  by  immediate  union,  inflammation 
forms  no  necessary  part  of  the  process ;  rather,  its  presence  always 
hinders  and  may  completely  prevent  it.  The  healing  by  immediate 
union  should  be  a  simple  rejoining  of  the  several  parts  without  the 
production  of  any  new  material ;  and  in  the  same  proportion  as,  in  any 
case,  inflammatory  matter  is  efl"used,  either  in  or  between  the  wounded 
parts,  in  that  proportion  does  the  healing  deviate  from  the  true  and 
best  process  of  immediate  union. 

2.  For  subcutaneous  wounds  and  injuries,  as  in  divided  tendons, 
simple  fractures,  and  the  like,  nearly  the  same  may  be  said.  Inflam- 
mation is  excited  by  the  local  injury,  but  its  products  form  no  neces- 
sary part  of  the  material  of  repair  ;  rather,  the  more  abundant  they 
are,  the  more  acute  the  inflammation  is;  and  the  longer  it  continues, 
the  less  speedy  and  the  less  perfect  is  the  process  of  repair.  For  here 
the  necessary  or  best  reparative  material  is  a  substance  which  is  pro- 
duced without  the  signs  of  coexistent  inflammation,  and  of  which  the 
development  is  different  from  that  of  the  inflammatory  products  that 
are  mingled  with  it.  And  this,  which  is  most  evident  in  the  case  of 
the  healing  of  subcutaneous  injuries  by  bonds  of  connection,  is  probably 
equally  true  in  the  case  of  subcutaneous  granulations. 

8.  In  the  healing  of  a  wound  by  primary  adhesion,  or  by  open  granu- 
lations, we,  usually,  have  evidence  of  a  process  of  inflammation,  in  the 
first  instance,  in  the  presence  of  its  ordinary  signs,  in  a  degree  gene- 
rally proportioned  to  the  severity  and  extent  of  the  injury. 

4.  Still,  in  these  cases,  the  signs  of  an  inflammatory  process  are 
often  absent ;  and  even  when  they  exist,  the  process  appears  necessary 
for  no  more  than  the  production  of  the  organizable  matter,  and,  in  the 
case  of  granulations,  for  the  production  of  only  the  first  portions  of  it. 
The  right  formation  of  the  cells,  and,  yet  more  evidently,  their  higher 
organization  into  connective  and  other  tissues,  ensue  only  while  the 
signs  of  inflammation  are  absent.  They  are  manifestly  hindered  or 
prevented  when  signs  of  inflammation  are  present,  or  when  its  existence 
may  be  suspected  in  consequence  of  the  presence  of  some  irritation,  as 
a  foreign  body,  dead  bone,  or  the  like.  The  continuance  of  suppura- 
tion, also,  during  the  process  of  healing,  is  no  proof  of  the  continuance 
of  inflammation,  if  the  account  that  I  have  given  of  pus  be  true. 

In  these  two  modes  of  healing,  therefore,  we  may  conclude  that  in- 
flammation is  sometimes  absent,  and  is,  in  any  case,  only  partially,  and 
at  one  period,  requisite  ;  and  that,  in  regard  to  its  requisite  degree,  the 
least  amount  with  which  an  exudation  of  lymph  is  possible,  is  that 
which  is  most  favorable  to  repair. 

5.  For  the  process  of  healing  by  scabbing,  the  absence  of  inflamma- 
tion appears  to  be  essential ;  indeed  the  liability  of  our  own  tissues  to 
the  inflammatory  process,  and  to  the  continued  exudation  that  it  pro- 


208  PHENOMENA     OF    INFLAMMATION: 

duces,  appears  to  be  that  which  prevents  their  injuries  from  being  healed 
as  easily  and  surely,  by  the  scabbing  process,  as  nearly  all  open  wounds 
are  in  animals. 

Lastly,  in  certain  cases,  the  artificial  production  of  an  inflammatory 
process  is  necessary  for  repairs  for  which  the  natural  processes  are  in- 
sufficient or  insecure.  Among  these,  are  the  cases  of  fractures  remain- 
ing disunited,  and  of  arteries  and  veins  needing  ligatures. 

Such  may  be  regarded  as  the  relations  of  the  reparative  process  to 
that  of  inflammation,  as  it  is  commonly  understood ;  but  I  repeat,  such 
a  comparison  can  be  made  only  for  the  sake  of  deference  to  the  general 
state  of  opinion  in  matters  of  surgical  pathology.  In  truth,  we  know 
less  of  inflammation  than  of  the  reparative  process. 


LECTURE  XIIL 

PHENOMENA    OF    INFLAMMATION. 

It  is  no  more  than  the  truth  which  Mr.  Travers  has  well  expressed 
in  his  work  on  the  "  Physiology  of  Inflammation  and  the  Healing  Pro- 
cess"— "  that  a  knowledge  of  the  phenomena  of  inflammation,  the  laws 
by  which  it  is  governed  in  its  course,  and  the  relations  which  its  several 
processes  bear  to  each  other,  is  the  keystone  to  medical  and  surgical 
science." 

I  shall  not  attempt  to  define  infiammation  in  any  set  terms ;  for  as 
yet  we  are  not,  I  think,  in  a  position  to  do  this.  Just  definitions  can- 
not be  made  in  any  science  till  some  of  its  broad  and  very  sure  princi- 
ples have  been  established.  Such  principles  we  cannot  boast  to  have 
yet  attained  in  the  study  of  pathology  ;  and  the  attempts  at  precise 
definitions  that  have  been  made  hitherto,  seem  to  have  led  to  confusion, 
or  to  false  and  narrow  views  of  truth.  Besides,  to  define  inflammation 
is  the  less  necessary,  because,  practically,  we  all  know  sufficiently  well 
what  the  term  implies  :  we  know  the  signs  of  the  presence  of  the  disease 
in  all  its  chief  forms ;  and,  when  we  watch  these  signs  in  any  external 
part,  we  see  them  so  often  followed  by  peculiar  changes  in  the  part,  that 
we  are  justified  in  recognizing  the  changes  as  efl"ects  of  inflammation, 
and  in  believing  that  wherever  we  find  them,  the  similar  or  correspond- 
ing signs  of  inflammation  have  preceded  them. 

But  the  very  difficulty  of  exactly  defining  the  process  of  inflamma- 
tion may  be  our  guide  to  the  most  hopeful  method  of  investigating  it. 
When  we  see  such  gradual  transitions  from  the  normal  process  of  nu- 
trition to  the  disease  of  inflammation,  that  we  cannot  draw  a  definition- 
line  between  them,  we  may  be  sure  that  the  main  laws  of  physiology 
are  the  laws  alike  of  the  disease  and  of  the  healthy  process ;  that  the 


STATE     OF    THE    BLOODVESSELS.  209 

same  forces  are  engaged  in  both  ;  and  that,  though  interfered  with  by 
the  conditions  of  the  disease,  they  are  not  supplanted  or  annulled. 

Now,  such  transitions  from  the  normal  processes  to  that  of  inflamma- 
tion are  not  rare.  We  may  trace  them,  for  example,  in  the  gradual 
passage  from  the  active  exercise  of  the  brain,  or  of  the  retina,  to  its 
"  irritation"  when  overworked,  and  thence  to  its  complete  inflammation 
and  impairment  of  structure,  after  long  exposure  to  what  had  been  a 
natural  stimulus,  or  to  what,  in  a  less  degree,  might  be  so.  Or,  on  the 
introduction  of  medicines,  such  as  certain  diuretics,  into  the  blood,  we 
may  trace  gradations  from  the  normal  increase  of  the  functions  of  the 
kidneys,^  under  what  is  regarded  as  no  morbid  stimulus,  to  their  intens- 
est  inflammations.  Or,  again,  in  the  application  of  an  abnormal  stimu- 
lus, such  as  that  of  a  heat  greater  than  the  natural  temperature  of  the 
body,  where  shall  we  mark  the  line  at  which  inflammation  begins  to 
supervene  on  health  ?  We  may,  indeed,  say  that  stagnation  of  blood, 
or  effusion  of  liquor  sanguinis,  or  some  exudation,  or  some  degenerative 
change  in  the  elements  of  the  affected  tissue,  shall  be  the  condition  sine 
qua  non  of  inflammation  ;  we  may  call  whatever  falls  short  of  these, 
"  active  congestion,"  "  irritation,"  or  by  any  other  name  ;  but,  in  reality, 
such  distinctions  are  often  impossible,  and  sometimes  untrue,  and  in 
study,  the  terms  are  convenient  for  the  sake  of  brevity  rather  than  of 
clearness. 

Evading,  then,  the  question  of  the  precise  definition  of  inflammation, 
I  shall  endeavor,  first,  to  describe  the  state  of  an  inflamed  part,  giving 
to  the  description  such  a  plan  and  direction  as  may  best  help  the  chief 
design — first,  of  contrasting  the  inflammatory  with  the  normal  method 
of  nutrition  ;  and,  secondly,  of  showing  that  the  immediate  causes,  and 
the  chief  constituents,  of  the  inflammatory  state,  are  to  be  found  in 
alterations  of  those  things  which  are  necessary  conditions  of  the  healthy 
nutrition  of  a  part.  It  will  be  easy  to  connect  with  such  a  description 
the  explanations,  so  far  as  they  can  be  given,  of  the  constituent  signs  or 
phenomena  of  inflammation, — the  redness,  swelling,  heat  and  pain,  and 
the  disturbed  function  of  the  part. 

The  conditions  of  the  healthy  maintenance  of  any  part  by  nutrition, 
are,  as  illustrated  in  the  earlier  lectures — 1st,  a  regular  and  not  far 
distant  supply  of  blood  ;  2d,  a  right  state  and  composition  of  that  blood ; 
3d  (at  least  in  most  cases),  a  certain  influence  of  the  nervous  force  ;  and, 
4th,  a  natural  state  of  the  part  in  which  nutrition  is  to  be  effected.  All 
these  are  usually  altered  in  inflammation. 

1.  The  supply  of  blood  to  an  inflamed  part  is  altered,  both  by  the 
changes  of  the  bloodvessels,  especially  by  their  enlargement,  and  by  the 
mode  in  which  the  blood  moves  through  them. 

The  enlargement  of  the  bloodvessels  is,  I  suppose,  a  constant  event 
in  the  inflammation  of  a  part ;  for,  although  in  certain  parts,  as  the 
cornea,  the  vitreous  humor,  and  the  articular  cartilages,  some  of  the  signs 


210 


PHENOMENA    OF    INFLAMMATION; 


Fig.  28. 


or  eiFects  of  inflammation  may  be  found  where  there  are  naturally  no 
bloodvessels,  yet  I  doubt  whether  these  ever  occur  without  enlargement 
of  the  vessels  of  the  adjacent  parts,  and  especially  of  those  vessels  from 
which  the  diseased  structure  derives  its  natural  supply  of  nutritive  ma- 
terial, and  which  may  therefore  be  regarded  as  its  bloodvessels,  not  less 
than  those  of  the  part  in  which  they  lie.  Thus,  in  inflammation  of  the 
cornea,  the  vessels  of  the  sclerotica  and  conjunctiva  are  enlarged,  and 
in  ulceration  of  articular  cartilages  those  of  the  surrounding  synovial 
membrane-  or  subjacent  bone. 

•  The  enlargement  usually  afiects  alike  the  arteries,  the  capillaries,  and 
the  veins  of  the  inflamed  part ;  and  usually  extends  to  some  distance 

beyond  the  chief  seat  or  focus  of  the 
inflammation.  To  it  we  may  ascribe 
the  most  constant  visible  sign  of  in- 
flammation, the  redness,  as  well  as 
much  of  the  swelling.  Its  amount  is 
various  ;  it  may  be  hardly  perceptible, 
or  it  may  increase  the  vessels  to  two 
or  three  times  their  natural  diameter. 
Extreme  enlargement  is  admirably 
shown  in  Hunter's  specimen*  of  the 
two  ears  of  a  rabbit,  of  which  one  was 
inflamed  by  thawing  it  after  it  had  been 
frozen.  "  The  rabbit  was  killed  when 
the  ear  was  in  the  height  of  inflamma- 
tion, and,  the  head  being  injected,  the 
two  ears  were  removed  and  dried."  A 
comparison  of  the  ears,  or  of  the  draw- 
ings from  them  (Fig.  28),  shows  all  the 
arteries  of  the  inflamed  ear  three  or 
four  times  larger  than  those  of  the 
healthy  one,  and  many  arteries  that  in 
the  healthy  state  are  not  visible,  are, 
in  the  inflamed  state,  brought  clearly  into  view  by  being  filled  with  blood. 
I  have  repeatedly  seen  similar  enlargements  of  both  arteries,  and 
veins,  and  capillaries,  in  the  stimulated  wings  and  ears  of  bats.  The 
like  phenomena  occur  in  the  webs  of  frogs,  and  oth'er  cold-blooded 
animals ;  but  in  these,  I  think  the  amount  of  enlargement  is  generally 
less.f 

The  redness  of  an  inflamed  part  always  appears  more  than  is  pro- 
portionate to  the  enlargement  of  its  bloodvessels ;  chiefly  because  the 
red  corpuscles  are  much  more  closely  crowded  than  they  naturally  are 


*  Museum  of  the  College,  No.  71.     See,  also,  Hunter's  Works,  vol.  iii.  p.  323,  and  pi.  xx. 

f  Emmert,  who  is  among  the  few  that  have  measured  it,  says  it  is  equal  to  one-half  or 
one-third  of  the  normal  diameter  of  the  vessels.  Lebert  says  one-sixth  to  one-third  (Gazette 
M^dicale,  Mai  15,  1852). 


STATE     OF    THE    BLOODVESSELS.  211 

in  the  bloodvessels.  The  vessels  of  an  inflamed  part  are  not  only  di- 
lated, but  appear  crammed  with  the  red  corpuscles,  which  often  lie  or 
move  as  if  no  fluid  intervened  between  them  :  their  quantity  is  increased 
in  far  greater  proportion  than  that  of  the  liquid  part  of  the  blood. 

This  peculiarity  is  even  more  manifest  in  the  frog  than  in  the  bat ; 
for  in  the  former,  the  crowding  of  corpuscles  may  occur  in  vessels  that 
appear  to  have  undergone  no  change  of  size  on  the  application  of 
the  stimulus.* 

Another,  but  a  minor,  cause  of  the  increased  redness  of  the  inflamed 
part,  is  sometimes  to  be  observed  in  the  oozing  of  the  coloring  matter 
of  the  blood-corpuscles,  both  into  all  the  interspaces  between  them,  and 
through  the  walls  of  the  small  vessels  into  the  adjacent  tissue.  During 
life  this  may  be  noticed,  especially  when  the  blood  is  stagnant  in  the 
vessels,  and  it  may  give  them  a  hazy,  ruddy  outline ;  but  it  is  generally 
much  more  considerable  after  death,  when  we  may  ascribe  to  it  no  small 
portion  of  the  redness  that  an  inflamed  part  may  still  present. 

In  the  state  of  inflammation  no  new  bloodvessels  are  formed.  Many 
more  may  come  into  view  than  were  at  first  seen  in  the  part ;  but  these 
are  only  such  as  were  invisible  till  the  flood  of  blood-corpuscles  filled 
and  distended  them.  So  it  was  in  the  rabbit's  ears  ;  in  the  healthy  ear 
no  trace  can  be  seen,  with  the  naked  eye,  of  any  vessels  corresponding 
with  one  of  the  largest,  or  with  many  of  those  of  inferior  size,  in  the 
inflamed  ear.  So  it  is,  too,  in  microscopic  examinations.  Within  half 
an  hour  after  stimulating  a  bat's  wing,  many  vessels  may  come  into 
view  which  could  not  be  seen  before  with  the  same  lens,  and  with  which 
none  can  be  seen  corresponding  in  the  other  wing,  though  doubtless 
such  vessels  exist  there  of  smaller  size.        , 

It  is  only  when  the  inflammation  has  subsided,  and  the  lymph  exuded 
from  the  bloodvessels  begins  to  be  more  highly  organized,  that  new 
vessels  are  formed,  and  pass  into  the  lymph,  as  if  for  the  maintenance 
of  its  increase  or  development. f  So  long  as  the  inflammation  lasts, 
the  intensest  redness  in  parts  naturally  colorless, — even  such  as  we 
see  in  acute  inflammations  of  the  conjunctiva,  or  yet  more  remarkably 
in  those  of  periosteum, |  or  in  congestion  of  the  stomach, — is  due  to  the 
enlargement  of  the  natural  bloodvessels,  to  their  admitting  crowded  red 

*  I  do  not  more  particularly  refer  to  what  is  described  as  the  encroachment  of  the  red 
blood-corpuscles  on  the  lymph-space,  or  the  layer  of  fluid  that  lies  in  apparent  rest  adhering 
to  the  walls  of  the  vessels.  The  too  pointed  description  of  this  layer  has  led  to  exaggerated 
notions  concerning  it.  Its  existence  is  certain,  but  it  is  too  thin  for  any  blood-corpuscle  to  lie 
at  rest  in  ;  and  when  white  corpuscles  remain  by  the  walls  of  the  vessels,  it  is  evident  that 
they  do  so  more  because  of  their  own  adhesiveness  than  because  a  small  portion  of  the 
fluid  about  them  is  at  rest. 

■f  Mr.  Hunter  held  this  opinion  ;  but  more  lately  the  contrary  one  has  been  commonly 
held.     See  his  Works,  vol.  iii,  p.  322. 

X  As  illustrated  in  Mr.  Stanley's  plates,  plate  vii,  Fig.  1,  which  represents  a  specimen  in 
the  Museum  of  St.  Bartholomew's,  Series  i.  No.  195.  The  whole  inner  surface  of  the  in- 
flamed periosteum  of  a  tibia  is  bright  scarlet. 


212 


PHENOMENA    OF    INFLAMMATION: 


corpuscles,  and  in  a  mucli  less  degree,  and,  perhaps,  in  only  certain 
cases,  to  the  diffusion  of  the  coloring  matter  of  the  blood.   • 

With  the  enlargement  of  the  bloodvessels  a  change  of  shape  is  com- 
monly associated.  Being  usually  elongated  as  well  as  dilated,  they  are 
thrown  into  curves,  and  made  more  or  less  wavy  or  tortuous.  Thus  we 
may  see  the  larger  vessels  in  an  inflamed  conjunctiva,  and,  more  plainly, 
the  subperitoneal  arteries  in  cases  of  peritonitis ;  so,  too,  they  are  repre- 
sented in  the  rabbit's  inflamed  ear. 

A  more  remarkable  change  of  shape  of  the  small  vessels  of  inflamed 
parts  is  that  in  which  they  become  aneurismal  or  varicose.  The  first 
observations  of  this  state  were  published,  I  believe,  by  Kolliker  and 
Hasse,  in  an  account  of  a  case  of  inflammatory  red  softening  of  the 
brain,  in  which  many  of  what,  at  first  sight,  appeared  to  be  points  of 
extravasated  blood,  proved  to  be  dilatations  of  capillary  vessels  filled 
with  blood.  After  this  they  found  the  same  changes,  but  in  a  much 
less  degree,  in  some  cases  of  inflammation  artificially  excited  in  the 
brains  of  rabbits  and  pigeons.*  Many,  as  well  as  myself,  have  since 
made  similar  observations,  most  of  which,  however,  seem  to  show  that 
the  peculiar  dilatation  has  its  seat  in  the  small  arteries  and  veins,  as 
well  as  in  the  capillaries  of  the  inflamed  part. 

Among  the  various  forms  of  partial  dilatation,  some  are  like  gradual 
fusiform  dilatations  of  the  whole  circumference  of  the  vessel ;  some  like 

shorter  and  nearly  spheri- 
^^'  cal  dilatations  of  it ;  some 

like  round,  or  oval,  or 
elongated  pouches,  dilated 
from  one  side  of  the  wall : 
in  short,  all  the  varieties 
of  form  which  we  have 
long  recognized  in  the 
aneurisms  and  aneurismal 
dilatations  of  the  great 
arteries  may  be  found  in 
miniature  in  the  small  ves- 
sels of  such  inflamed  parts. 
Some  of  these  forms  are 
represented  in  Fig.  29, 
from  the  small  vessels  of 
an  inflamed  pericardium. 
Frequently,  however,  as  this  state  of  the  small  vessels  has  been  ob- 
served in  inflamed  parts  (and  I  believe  some  measure  of  it  may  be 
found  in  the  inflammations  of  most  membranes),t  yet,  I  think,  we  may 

*  Zeitschr.  fur  wissensch.  Zoologie,  B.  i,  p,  262.  Mr.  Kiernan  had  observed  the  same 
changes  some  years  previously.     See  Dr.  Williams's  Principles  of  Medicine,  2d  edit.,  p.  287. 

t  Lebert  says  it  is  a  constant  occurrence  in  experimental  inflammations  of  the  subcutane- 
ous tissue  of  frogs.    (Gazette  Medicale,  Mai,  22,  1852.) 


STATE    OF    THE    BLOODVESSELS.  213 

not  assume  it  to  have  a  necessary  or  important  connection  with  the 
other  phenomena  of  inflammation.  It  is  often  observed,  as  Virchow* 
especially  has  shown,  in  other,  besides  inflammatory,  diseases ;  and,  in 
all  alike,  may  be  referred  to  a  gradual  deterioration  of  the  structure  of 
the  vessels,  weakening  them,  and  rendering  them  unable  to  resist 
uniformly  the  increased  pressure  of  the  blood. 

Such  is  the  ordinary  state  of  the  bloodvessels  of  an  inflamed  part : 
all  dilated  and  elongated,  tensely  filled  with  blood,  of  which  the  red 
corpuscles  are  in  excess,  often  wavy  and  tortuous,  and  sometimes 
variously  aneurismal. 

But  the  supply  of  blood  to  an  inflamed  part  is  aff"ected  by  its  mode  of 
movement,  as  well  as  by  the  size  of  the  bloodvessels :  this,  therefore,  I 
must  now  describe. 

Nearly  all  the  observations  hitherto  recorded,  on  the  morbid  changes 
in  the  movement  of  the  blood,  have  been  made  with  the  webs  of  frogs ; 
and  it  has  been  objected  that  it  is  not  safe  to  apply  conclusions  drawn 
from  them  to  the  case  of  warm-blooded  animals.  I  have  therefore  em- 
ployed the  wings  of  bats,  in  which  (when  one  has  acquired  some  art  in 
quieting  them  with  chloroform  or  gentle  management)  nearly  all  the 
phenomena  of  the  circulation,  as  efi"ected  by  the  application  of  stimuli, 
may  be  watched  as  deliberately  as  in  the  frog,  and  in  some  respects 
even  more  clearly. 

I  think  we  may  believe  that  what  may  be  seen  in  the  wings  of  bats 
occurs,  in  the  like  circumstances,  in  all  warm-blooded  animals.  It  is 
true  that,  like  the  other  hybernants,  the  bats,  while  they  are  in  their 
winter-sleep,  resemble  the  cold-blooded  animals,  in  that  their  tempera- 
ture is  conformed  to  that  of  the  external  air,  and  scarcely  exceeds  it. 
It  is  true,  also,  that  when  they  are  ill-nourished,  their  temperature, 
even  in  their  active  state,  is  comparatively  low,  ranging  from  65°  to 
80°  F.,  in  an  atmosphere  of  60° ;  and  that  generally  they  are  liable  to 
much  greater  diversities  of  temperature  than  our  own  bodies  are.f   And 

*  In  his  Archiv,  B.  iji,  p.  432. 

f  For  instance,  I  found  the  temperature  of  a  strong  and  active  Noctule  Bat  ( Vespertilio 
Noctuld)  thus  various  in  two  days : 

April  29th,  at  noon,  after  he  had  been  nearly  two  hours  under  the  influence  of  chloro- 
form, and  on  awaking  had  been  struggling  very  actively,  his  temperature  was  99°  F.  At 
9  P.M.,  having  meantime  been  quiet,  hanging  by  his  hind  feet,  and  looking  sickly,  his  tem- 
perature was  only  70°.  When  disturbed  he  became  very  fierce  and  active,  shrieking  and 
biting  the  bars  of  his  cage;  and  at  9h.  40m.,  his  temperature  was  92°.  Soon  after  this  he 
became  quiet  again,  and  at  lOh.  30m.  his  temperature  was  80°.  The  temperature  of  the 
atmosphere  during  these  examinations  had  gradually  increased  from  61°  to  67°. — April 
30th,  at  8  A.M.,  he  was  feeble,  but  not  torpid  :  the  temperature  of  the  room  during  the  night 
had  been  between  40°  and  45°,  and  was  now  57° ;  the  temperature  of  the  bat  was  only 
59°.  At  11  A.M.,  after  struggling  violently  for  half  an  hour,  it  rose  to  69°.  After  being  long 
under  chloroform,  and  nearly  dying,  he  remained  all  the  afternoon  only  one  or  two  degrees 
warmer  than  the  atmosphere.  But  at  night,  at  12 h.  15rn.,  he  recovered  and  became  active  ; 
and,  while  the  atmosphere  was  at  65°  he  was  at  85°.     At  12h.  40m.,  after  being  made  very 


214  PHENOMENA    OF    INFLAMMATION: 

the  remarkable  condition,  discovered  by  Mr.  Wharton  Jones,*  that 
those  veins  in  the  wing  that  have  valves  contract  with  regular  rhythm 
for  the  acceleration  of  the  venous  stream,  may  eifect  in  some  measure 
the  morbid  as  well  as  the  normal  movement  of  the  blood.  Still,  since 
in  the  development  of  their  nervous  system,  and  the  commensurate 
development  of  their  heart  and  respiratory  organs,  and  in  the  close 
reciprocal  relations  in  which  these  act,  the  bats  resemble  the  other 
warm-blooded  vertebrata,  we  may,  I  think,  fairly  assume  a  close  resem- 
blance also  in  their  processes  and  conditions  of  nutrition. 

The  simplest  effects  upon  the  bloodvessels  are  produced  by  a  slight 
mechanical  stimulus.  If,  as  one  is  watching  the  movement  of  blood  in  a 
companion  artery  and  vein,  the  point  of  a  fine  needle  be  drawn  across 
them  three  or  four  times,  without  apparently  injuring  them  or  the  mem- 
brane over  them,  they  will  both  presently  gradually  contract  and  close. 
Then,  after  holding  themselves  in  the  contracted  state  for  a  few  minutes, 
they  will  begin  again  to  open,  and,  gradually  dilating,  will  acquire  a 
larger  size  than  they  had  before  the  stimulus  was  applied.f 

Simple  as  this  observation  is,  it  involves  some  cardinal  facts  in  our 
pathology.  It  illustrates  first,  the  contractile  power  of  both  arteries 
and  veins ;  it  shows  that  this  is  possessed  by  the  smallest,  just  as  it  is 
by  the  larger,  vessels  of  both  kinds  ;  and  by  the  manner  of  their  con- 
traction, which  follows  at  some  interval  after  the  application  of  the 
stimulus,  and  is  slowly  accomplished,  it  shows  that  their  power  of  con- 
traction is  like  that  of  parts  with  smooth  or  organic  muscular  fibres. 

But,  again,  the  experiment  shows  the  vessels  reopening  and  becom- 
ing wider  than  they  were  before  ;  either  yielding  more  to  the  pressure 
of  the  blood  which  previously  they  resisted  with  more  strength,  or  else 

fierce,  he  was  at  88°;  and  at  Ih.  30m.  remained  at  85°.  Next  morning  he  was  again 
scarcely  warmer  than  the  atmosphere.  The  temperature  was  always  taken  with  a  small 
thermometer  applied  to  the  surface  of  the  abdomen. 

*  Philos.  Trans.,  1852,  Part  I. 

f  Some  doubt  has  been  expressed  as  to  the  contraction  of  the  veins  here  described,  for 
Mr.  Wharton  Jones  has  not  been  able  to  convince  himself  of  it.  He  considers,  also,  that  in 
the  frog's  web  the  veins  are  capable  of  but  slight  variation  in  diameter  through  the  opera- 
tion of  contractile  power;  and  this  accords  with  E.  H.  Weber's  observations  (Miiller's  Ar- 
chiv,  1847).  Lebert,  on  the  other  hand,  expressly  says  that  he  has  observed  the  same  vari- 
ous states  of  contraction  in  the  veins  as  in  the  arteries  of  the  frog's  v^eb.  In  most  other 
points  relative  to  the  condition  of  the  bloodvessels,  and  the  movement  of  the  blood  in  them, 
my  observations  accord  with  those  which  Mr.  Wharton  Jones  had  completed,  but  not  pub- 
lished, when  the  lectures  were  delivered.  The  reader  may,  however,  find  in  his  admira- 
able  essay  (Guy's  Hospital  Reports,  1851),  many  minute  details  which  I  had  not  learned, 
and  many  illustrations  of  singular  beauty  and  accuracy. 

Mr.  Lister  (Phil.  Trans.,  1858,  p.  656)  has  observed  a  considerable  degree  of  local  con- 
traction on  one  occasion  in  the  vein  of  a  frog's  w^eb,  although  generally  they  do  not  exhibit 
great  contractile  properties,  and  in  man  and  some  of  the  higher  animals  he  has  noticed  seve- 
ral striking  examples  of  the  contractility  of  the  larger  veins.  In  the  same  paper,  p.  653, 
and  in  Trans  Roy.  Soc.  Edin.,  vol.  xxi,  p.  549,  he  has  carefully  described  the  arrangement  of 
the  muscular  fibre-cells  in  the  walls  of  the  small  arteries.  Leydig  again  (Archiv  f.  Anat. 
and  Phys.  1859)  has  stated  that  the  muscular  fibres  of  the  veins  of  the  wing  of  the  bat  ex- 
hibit evidences  of  transverse  striation. 


STATE     OF     THE     BLOODVESSELS.  215 

dilating,  as  of  their  own  force,  with  that  which  Mr.  Hunter  called  active 
dilatation,  and  compared  with  the  act  of  dilatation  of  the  os  uteri.  In 
whichever  way  the  dilatation  is  effected,  whether  it  be  active  or  passive, 
the  vessels  will  not  at  once  contract  again  under  the  same  stimulus  as 
before  affected  them.  The  needle  may  be  now  drawn  across  them  much 
often er  and  more  forcibly,  but  no  contraction  ensues,  or  only  a  trivial 
one,  which  is  quickly-  succeeded  by  dilatation.  Yet  with  a  stronger 
stimulus,  such  as  that  of  great  heat,  they  will  again  contract  and  close. 
And  such  a  contraction  excited  by  a  cautery  may  last  more  than  a  day, 
before  the  vessels  again  open  and  permit  the  flow  of  the  blood  through 
them. 

Moreover,  we  may  observe  in  this  experiment  the  adapted  movement 
of  the  blood.  As  the  vessels  are  contracting  the  blood  flows  in  them  more 
slowly,  or  begins  to  oscillate ;  nay,  sometimes,  I  think  even  before  the  ves- 
sels begin  visibly  to  contract,  one  may  observe  that  the  blood  moves  more 
slowly  in  them,  as  if  this  were  an  earlier  effect  of  the  stimulus  :  nor  have 
I  ever  seen  (what  has  been  commonly  described)  the  acceleration  of  the 
flow  of  blood  in  the  contracting  vessels.  Such  an  acceleration,  how- 
ever, is  manifest,  as  the  vessels  reopen  ;  and  as  they  dilate,  so,  appa- 
rently in  the  same  proportion,  does  the  flow  of  blood  through  them  become 
more  free,  till,  at  length,  it  is  manifest  that  they  are  traversed  by  both 
fuller  and  more  rapid  streams  than  passed  through  them  before  the 
stimulus  was  applied.  How  long  this  state  may  last  depends  on  many 
circumstances  hard  to  estimate ;  but  at  length  it  ceases,  and  the  vessels, 
and  the  circulation  through  them,  assume  again  their  average  or  normal 
state. 

Such  are  the  effects  of  the  mechanical  stimulus  of  bloodvessels. 

The  effects  of  other  stimuli  applied  to  the  wings  of  bats  correspond 
in  kind,  but  differ  in  degree  and  extent.  If  a  drop  of  acetic  acid,  of 
tincture  of  capsicum,  of  turpentine,  or  of  ethereal  solution  of  cantha- 
rides,  be  placed  on  a  portion  of  the  wing,  or  washed  over  it,  one  sees  a 
quickly  ensuing  dilatation  of  the  bloodvessels,  and  a  rapid  flow  of  blood 
through  them  all.  I  am  not  sure  that  the  dilatation  is  preceded  by  con- 
traction. Certainly  the  contraction  is  very  slight,  if  it  occur  at  all ; 
but  the  dilatation  is  usually  much  more  extensive.  When  the  stimulus 
has  been  applied  to  only  one  small  spot  upon  the  wing,  the  whole  of  the 
bloodvessels  in  the  corresponding  metacarpal  space,  and  even  those  of 
the  adjacent  spaces,  may  enlarge.  One  might  imagine  that  the  dilata- 
tion of  vessels  was  due  to  an  increased  action  of  the  heart,  if  it  were 
not  that  (as  I  think)  it  is  always  greater  at  the  very  point  to  which  the 
stimulus  was  applied  than  in  any  other  part  of  the  same  wing,  and  is 
never  at  all  imitated  in  the  corresponding  parts  of  the  opposite  wing. 

The  state  which  is  thus  induced  by  stimuli  is  what  is  commonly  under- 
stood by  the  expressions  "active  congestion,"  or  "determination  of 
blood,"  in  a  part.  It  consists,  briefly,  in  general  enlargement  of  the 
bloodvessels  of  the  part,  with  an  increased  velocity  of  the  blood  in  them. 


216  PHENOMEITA     OF    INFLAMMATION: 

It  is,  probably,  just  sucb  a  state  as  this  that  is  felt  by  suckling  women 
in  what  they  term  the  "  flow  of  milk,"  It  seems  to  be  an  increased 
flow  of  blood  in  the  mammary  gland  just  before  a  quicker  secretion  of 
the  milk.  Less  normally,  it  is  such  a  state  as  this  that  we  observe  in 
the  skin  after  the  application  of  mustard,  or  sharp  friction,  or  a  heat 
from  20°  to  50°  above  its  own,  or  in  the  most  striking  instance,  when  a 
drop  of  strongest  nitric  acid  is  placed  on  the  skin,  and,  in  a  few  seconds, 
all  the  surrounding  area  seems  to  flush,  and  feels  burning  hot.  Such, 
too,  we  may  suppose  to  be  the  state  of  the  vessels  of  the  conjunctiva, 
when  stimulated  by  dust  that  is  soon  dislodged ;  and  such  the  condition 
of  many  internal  organs,  when  we  might  doubt  whether  they  are  in- 
flamed, or  are  only  very  actively  discharging  their  natural  functions. 
Herein,  indeed,  in  what  I  have  described  is  one  of  the  pieces  of  neutral 
ground  between  health  and  disease  :  a  step  in  one  direction  may  efi"ect 
the  return  to  health  ;  in  another  the  transit  to  what  all  might  admit  to 
be  the  disease  of  inflammation. 

Now,  this  transit  appears  to  be  made  when  the  circulation,  which  was 
rapid,  begins  to  grow  slower,  without  any  diminution,  but  it  may  be 
with  an  increase  of  the  size  of  the  vessels.  This  change  one  may  see 
in  the  bat's  wing.  After  the  application  of  such  stimuli  as  I  have  al- 
ready mentioned,  the  movement  of  the  blood  may  become  gradually 
slower,  till  in  some  vessels,  it  is  completely  stagnant.  The  stagnation 
commences,  according  to  Mr.  Wharton  Jones,  in  the  capillaries;  and 
first  in  those  which  are  least  in  the  direct  course  from  the  artery  to 
the  vein  (in  the  stimulated  frog's  web):  thence  it  extends  to  the  veins 
and  to  the  arteries. 

A  corresponding  state  of  retardation  of  blood,  leading  to  partial  stag- 
nation of  it,  may  be  well  seen  after  such  an  injury  as  that  of  a  fine  red- 
hot  needle  driven  into  or  through  the  membrane  of  the  wing. 

The  first  eff'ect  of  such  an  injury  (in  addition  to  the  charring  and 
searing  of  the  membrane,  the  obliteration  of  its  bloodvessels,  and  the' 
puckering  of  the  portion  of  it  adjacent  to  the  burn)  is  to  produce  con- 
traction of  the  immediately  adjacent  arteries  and  veins.  They  may 
remain  closed,  or,  as  I  have  already  described,  after  being  long  closed, 
may  again  open,  and  become  wider  than  they  were  before.  This  dilata- 
tion follows  more  certainly,  and  perhaps  without  any  previous  contrac- 
tion, in  the  arteries  and  veins  at  a  little  distance  from  the  burn.  In 
these,  there  speedily  ensues  such  a  state  of  "  determination  of  blood" 
as  I  have  already  described :  in  arteries  and  veins  alike  the  stream  is 
full  and  rapid ;  and  the  greater  accumulation,  as  well  as  the  closer 
crowding,  of  the  red  corpuscles,  makes  the  vessels  appear  very  deep- 
colored.  The  contrast  of  two  diagrams,  showing  the  natural  and  the 
stimulated  conditions  in  a  single  segment  of  the  vascular  plan  of  the 
wing,   illustrates  this  difierence  sufficiently  well*  (Figs.  30  and  31), 

*  The  plan  of  vessels  drawn  is  copied  from  a  portion  of  Mr,  Wharton  Jones's  plate. 
Philos.  Trans.  1852,  part  1,  plate  v. 


STATE    OF    THE     CIRCULATION. 


217 


The  vessels  of  the  one,  nearly  twice  as  large  as  those  of  the  other, 
darker,  and  more  turgid  with  blood  ;  and,  in  the  one,  numerous  capil- 

Fig.  30. 


laries  which  are  not  visible  in  the  other.  But  diagrams  cannot  show 
the  changes  in  the  mode  of  movement.  Close  by  the  burn,  the  blood 
which  has  been  flowing  rapidly  begins  to  move  more  slowly,  or  with  an 

Fig.  31. 


uncertain  stream  ;  stopping,  or  sometimes  ebbing,  and  then  again  flow- 
ing on,  but,  on  the  whole,  becoming  gradually  slower.  Thus  it  may,  at 
length,  become  completely  stagnant ;  and  then,  in  the  vessels  in  which 

15 


218  PHENOMENA    OF   INFLAMMATION: 

it  is  at  rest,  it  seems  to  diifuse  and  change  its  color,  so  that  its  crowded 
corpuscles  give  the  vessels  a  brilliant  carmine  appearance,  by  which, 
just  as  well  as  by-  the  stillness  of  the  blood,  they  may  always  be  dis- 
tinguished. As  one  surveys  an  area  surrounding  this  part,  one  sees 
streams  the  more  rapid  the  more  distant  they  are  from  the  focus  of  the 
inflammation.  And  often,  when  there  is  stagnation  in  a  considerable 
artery,  one  may  see  the  blood  above  or  behind  it  pulsating  with  every 
action  of  the  heart,  driven  up  to  the  seat  of  stagnation,  and  thence  car- 
ried off  by  the  collateral  branches  ;  while,  in  the  corresponding  vein,  it 
may  oscillate  less  regularly,  delaying  till  an  accumulated  force  propels 
it  forward,  and,  as  it  were,  flushes  the  channel.*  In  the  area  still  more 
distant,  one  sees  the  full  and  rapid  and  more  numerous  streams  of  "  de- 
termination" or  "  active  congestion,"  which  extend  over  a  space  alto- 
gether uncertain. 

Such  is  the  general  condition  of  the  circulation  in  and  around  apart 
that  is  inflamed.  In  a  few  words,  there  is,  in  the  focus  of  severe  in- 
flammation, more  or  less  of  stagnation  of  blood;  in  and  close  around  it, 
there  is  congestion, — i.  e.  fulness  and  slow  movement  of  blood  ;  more 
distantly  around  there  is  determination, — ^'.  e.  fulness  and  rapid  move- 
ment of  blood.  The  varieties  in  lesser  points  that  may  be  presented 
cannot  be  described.  These  must  be  seen  ;  and,  indeed,  the  whole 
sight  should  be  viewed  by  every  one  who  would  have  in  his  mind's  eye 
a  distinct  image  of  what,  in  practice,  he  must  often  too  obscurely  con- 
template. 

The  phenomena  that  I  have  described  as  seen  in  the  bat's  wing  cor- 
respond very  closely  with  those  observed  in  the  frog's  web.  Only,  I 
think  the  stagnation  of  blood  is  neither  so  constant  nor  so  extensive  in 
the  bat :  it  is  seen  in  portions  of  single  vessels,  rather  than  in  districts 
of  vessels  ;  often  in  corresponding  portions  of  arteries  and  veins,  as  they 
lie  side  by  side.  The  stagnation  usually  extends  into  such  branches  as 
may  be  given  from  the  vessels  that  are  its  principal  seats  ;  and  three  or 
four  such  seats  of  stagnation  may  appear  placed  irregularly  about  the 
burn,  or  other  focus  of  the  inflammation ;  but  I  have  never  seen  a  ge- 
neral stagnation  of  blood  in  all  the  vessels  of  even  a  severely  stimulated 
part.  My  impression  is,  that,  in  strong  and  active  warm-blooded  ani- 
mals, stagnation  of  blood  would  be  found  in  only  the  most  severely  in- 
flamed parts  :  in  others,  I  think,  retardation  alone  would  exist. 

To  sum  up  now  what  concerns  the  supply  of  blood  in  an  inflamed 
part.  We  seem  to  have  sufiicient  evidence  that,  in  general,  in  the  focus 
of  the  inflammation,  blood  is  present  in  very  large  quantity,  distending 
all  the  vessels,  gorging  them  especially  with  red  corpuscles,  but  often 
moving  through  them  slowly,  or  even  being  in  some  of  them  quite  stag- 
nant ;   that  all  around  this  focus,  the  vessels  are  as  full,  or  nearly  as , 

*  What  I  thus  described  was,  no  doubt,  the  result  of  the  rhythmical  contraction  of  the 
veins,  which  Mr.  Wharton  Jones  lias  since  discovered. 


STATE    OF    THE     CIRCULATION.  219 

full,  as  thej  are  in  it,  but  the  blood  moves  in  them  with  a  quicker 
stream,  or  may  pulsate  in  the  arteries,  and  oscillate  in  the  veins ;  that, 
yet  further  from  the  focus,  the  blood  moves  rapidly  through  full  but 
less  turgid  vessels.  And  this  rapidity  and  fulness  are  not  to  be  as- 
cribed, I  think,  merely  to  the  blood,  which  should  have  gone  through 
the  inflamed  part,  being  driven  through  collateral  channels,  but  are 
such  a  state  as  is  commonly  understood  as  an  "  active  congestion,"  or 
"determination  of  blood"  in  the  part.* 

I  have  already  said,  that  we  may  believe  that  what  is  seen  in  the  bat 
represents  fairly  the  state  of  inflamed  parts  in  all  warm-blooded  ani- 
mals. I  am  quite  conscious  that  the  most  one  can  see  with  the  micro- 
scope, in  these  experimental  inflammations,  is  but  a  faint  picture  of 
such  inflammations  as  we  have  to  consider  in  practice  ;  that  it  is  very 
trivial  in  both  its  appearance  and  its  results.  Still,  it  is  a  picture  of  a 
disease  of  the  same  kind  ;  and  a  miniature,  even  faintly  drawn,  may  be 
a  true  likeness.  Besides,  all  that  can  be  observed  of  the  complete  pro- 
cess of  inflammation  in  man  is  consistent  with  what  we  can  see  in  these 
lower  and  lesser  creatures.  The  bright  redness  of  an  inflamed  part 
testifies  to  the  fulness  of  its  bloodvessels,  and  the  crowding  of  the  cor- 
puscles ;  the  occasional  duskiness  or  lividity  of  the  focus  is  character- 
istic of  stagnation  ;  the  throbbing  in  the  part,  and  about  it,  and  the  full 
hard  pulse  in  the  ministrant  arteries,  are  sure  signs  of  obstruction  to 
the  passage  of  blood  ;  the  gush  of  blood  on  cutting  into  the  tissues  near 
an  inflamed  part,  or  in  bleeding  from  one  of  their  veins,  tells  of  the  de- 
termination of  blood  in  these,  and  of  the  tension  in  which  all  the  con- 
taining bloodvessels  are  held. 

It  is  particularly  to  be  observed  that  the  stagnant  or  retarded  blood 
is  not  apt  to  coagulate.  I  have  found  it  fluid  after  at  least  three  days' 
complete  stagnation,  and  so  I  believe  it  would  remain  till  it  is  cleared 
away,  unless  the  part  sloughs.  In  the  latter  case  it  would  coagulate, 
as  it  does  in  carbuncles  and  the  like,  which  hardly  bleed  when  we  cut 
them  through ;  but,  so  long  as  the  blood  is  fluid,  though  stagnant,  it 
may  be  driven  from  the  vessels  with  full  force,  as  soon  as  an  easy  exit 
for  it  is  made  by  cutting  into  the  inflamed  part,  or  opening  one  of  its 
large  veins.  I  need  only  here  refer  to  Mr.  Lawrence's  well-known  and 
instructive  experiment.  In  a  patient  with  an  inflamed  hand  he  made 
similar  openings  into  veins  in  both  arms.  From  the  vein  on  the  diseased 
side  three  times  more  blood  flowed  than  from  the  vein  in  the  healthy 

*  Professor  Lister  (Phil.  Trans.,  1858,  p.  658),  after  a  careful  inquiry  into  the  effects  of 
irritants  upon  the  circulation,  has  clearly  pointed  out  that  we  ought  to  make  a  distinction  be- 
tween that  dilatation  of  the  arteries,  which  induces  determination  of  blood  to  a  part,  and 
the  accumulation  of  corpuscles  in  the  capillaries,  which  causes  inflammatory  congestion. 
The  two  processes  differ  in  their  nature,  and  are  produced  by  independent  causes.  The 
first  is  due  to  a  relaxation  of  the  muscular  fibres  of  the  arterial  coats,  developed  through  the 
medium  of  the  nervous  system,  whilst  the  second  is  the  result  of  the  direct  action  of  the 
irritant  upon  the  tissues,  and  a  consequent  change  in  the  quality  of  the  blood  in  their 
vicinity. 


/ 


220  PHENOMENA    OE    INFLAMMATION: 

arm,  in  the  same  time.  This  increased  flow  represented  at  once  the 
greater  determination  of  blood  about  the  focus  of  the  inflammation,  and 
the  greater  tension  in  which  the  walls  of  the  bloodvessels,  and,  indeed, 
all  the  tissues  of  the  inflamed  and  swollen  part,  were  held. 

Now,  to  what  can  we  describe  these  changes  in  the  movement  of  the 
blood  ? 

It  has  been  commonly  said  that,  as  the  vessels  contract,  therefore  the 
movement  of  blood  becomes  more  rapid  in  them,  as  when  a  river  enter- 
ing a  narrow  course  moves  through  it  with  a  faster  stream ;  and  that 
then,  as  the  vessels  widen,  so  the  stream  becomes,  in  the  same  propor- 
tion, slower.  But  this  is  far  from  true.  The  stream  becomes  slower 
as  the  artery  or  vein  becomes  narrower  by  contraction;  and  then,  as 
the  tube  again  dilates,  the  stream  grows  faster ;  and  then,  without  any 
appreciable  change  of  size,  it  may  become  slower  again,  till  complete 
stagnation  ensues  in  at  least  some  part  of  the  bloodvessel.*  I  think  I 
can  be  quite  sure  that  the  velocity  of  the  stream,  in  any  vessel  of  an  in- 
flamed part,  is  not  wholly  determined  either  by  the  diminution  or  enlarge- 
ment of  the  channel,  or  by  the  stagnation  or  congestion  of  blood  in  the 
vessels  beyond.  That  much  of  the  change  in  rate  of  movement  depends 
on  these  conditions  cannot  be  doubted ;  and  it  may  seem  unnecessary  to 
question  their  sufiiciency  for  the  explanation  of  that  change,  after  Mr. 
Wharton  Jones's  observations.  But  I  think  other  forces  must  still  be 
considered,  whose  disturbance  may  contribute  to  the  result.  Whether 
we  name  it  vital  afiinity,  or  by  any  other  terms,  or  (which  may,  as  yet, 
be  better)  leave  it  unnamed,  I  cannot  but  believe  there  is  some  mutual 
relation  between  the  blood  and  its  vessels,  and  the  tissues,  or  other  sub- 
stances around  them,  which,  being  natural,  permits  the  most  easy  transit 
of  the  blood,  but,  being  disturbed,  increases  the  hinderances  to  its  pas- 
sage. Such  hinderances  appear  to  be  produced  by  the  addition  of  salts 
of  baryta,  or  of  potash,  to  the  blood  ;  and  by  an  excess  of  carbonic  acid 
in  the  blood  that  should  traverse  the  minute  pulmonary  vessels.  The 
presence  of  an  excess  of  urea  in  the  blood  probably  produces  the  like 
effect :  and  some  of  the  facts  connected  with  other  than  traumatic  in- 
flammations appear  quite  inexplicable  without  such  an  hypothesis  as 
this.f 

II.  I  mentioned,  as  the  second  condition  necessary  to  the  healthy 
nutrition  of  a  part,  a  right  state  and  composition  of  the  blood.  In  for- 
mer lectures  (p.  34,  et  seq.)  I  pointed  out  that,  by  this  state,  we  must 
understand  not  merely  such  purity  of  the  blood  that  chemistry  cannot 

*  As  Mr.  Wharton  Jones  has  shown,  the  retarded  stream  exists  only  when  the  vessel  is 
generally  contracted,  and  the  accelerated  stream  when  it  is  generally  dilated  :  when  a  single 
vessel  presents  successive  enlargements  and  diminutions  of  calibre,  the  rate  of  the  stream  in 
it  diminishes  in  the  former  and  increases  in  the  latter. 

t  Since  the  publication  of  the  first  edition  of  this  vi^ork,  the  correctness  of  the  view  ex- 
pressed in  the  text  has  been  fully  confirmed  by  the  observations  of  Mr.  Lister,  who  has  shown 
that  when  the  tissues  are  unhealthy,  the  blood  which  flows  near  them  acquires  properties 
that  render  it  unfit  for  transmission  through  the  minute  vessels.     See  note  to  page  223. 


STATE    OF    THE    BLOOD.  221 

detect  a  wrong  constituent  in  it,  or  a  wrong  quantity  of  any  of  tlie  ab- 
normal ones,  but  that  natural  constitution  of  the  blood  by  which  it  is 
exactly  adapted  to  every  tissue  that  it  has  to  nourish ;  with  an  adapta- 
tion so  exact  that  chemistry  often  cannot  approach  to  the  determination 
of  whether  it  is  maintained  or  lost. 

That  this  adaptation  is  disturbed,  in  many  cases  of  inflammation,  is 
proved  by  the  instances  to  which  I  shall  have  to  refer,  in  which  they 
plainly  have  their  origin  in  morbid  conditions  of  the  blood.  But  I  fear 
that  the  nature  of  this  disturbance  cannot  yet  be  chemically  expressed, 
and  the  facts  which  chemistry  has  discerned,  in  the  condition  of  the 
blood  in  inflammations,  cannot  yet  be  safely  applied  in  explanation  of 
the  local  process.  For,  first,  we  observe  the  phenomena  of  inflamma- 
tion where  we  cannot  suppose  the  whole  blood  disordered  ;  as  after  the 
application  of  a  minute  local  stimulus,  such  as  a  foreign  body  on  the  con- 
junctiva: secondly,  the  changes  observed  in  the  blood  during  inflamma- 
tions are  not  peculiar  to  that  state,  but  are  found  more  or  less  marked 
in  pregnancy,  and  in  other  conditions  in  which  no  inflammatory  process 
exists ;  and,  thirdly,  among  the  changes  observed  in  inflammatory 
blood,  the  principal  one,  namely,  the  supposed  increase  of  fibrine,  is 
ambiguous ;  it  may  be  at  once  an  increase  of  fibrine  and  of  the  white 
corpuscles  of  the  blood.  These  two  constituents  of  blood,  the  fibrine 
and  the  white  or  rudimental  corpuscles,  cannot  be  well  separated  by  any 
process  yet  invented ;  and  in  all  the  estimates  of  fibrine,  whether  in 
health  or  in  disease,  the  weight  of  the  white  corpuscles  is  included. 
Now,  in  many  inflammations  these  corpuscles  are  increased ;  and  in  such 
cases  we  have  no  means  of  clearly  ascertaining  how  much  of  an  appa- 
rent increase  of  fibrine  is  really  such,  and  how  much  is  due  to  the  cor- 
puscles entangled  in  the  fibrine.  Till  this  can  be  settled,  I  think  we 
may  not  deduce  any  of  the  local  phenomena  of  inflammation  from  the 
increase  of  fibrine  in  the  blood  ;  neither,  more  assuredly,  can  we  trace, 
as  some  do,  the  fever  and  other  general  signs  of  inflammation  to  the 
abstraction  of  fibrine  and  albumen  by  the  exudation  from  the  blood. 

The  other  principal  changes  of  the  blood  in  inflammation — the  dimi- 
nution of  its  red  corpuscles  and  increase  of  water — are  even  less  adapted 
to  explain  any  of  the  phenomena  of  the  local  process.  Whatever  may 
be  their  strength  or  value  as  facts,  they  are  as  yet  isolated  facts,  such 
as  we  cannot  weave  into  the  pathology  of  the  disease. 

I  fear,  too,  that  the  structural  condition  of  the  blood  will  not,  more 
than  the  chemical,  help  us  to  explain  the  phenomena  of  inflammation. 
Some  of  our  most  worthily  distinguished  pathologists  have  ascribed 
much  to  the  existence  of  large  numbers  of  the  white  blood-corpuscles, 
and  their  accumulation  in  the  vessels  of  the  inflamed  parts ;  indeed, 
they  have  taken  this  for  the  foundation  of  nearly  their  whole  doctrine 
of  inflammation,  ascribing  to  it  both  the  stagnation  of  the  blood  and 
the  changes  it  is  presumed  to  undergo  ;  such  as  the  increase  of  the 
fibrine,  and  many  others.     But  the  statements  on  which  they  have 


222  PHENOMENA    OF    INFLAMMATION: 

rested  are  unsound :  their  observations  have  been  made  on  frogs,  and 
do  not  admit  of  application  to  our  own  case,  or,  perhaps,  to  that  of  any 
warm-blooded  animal. 

In  many  frogs,  especially  in  those  that  are  young,  or  sickly,  or  ill- 
fed,  the  white  corpuscles  are  abundant  in  the  blood.  They  are  rudi- 
mental  blood-cells,  such  as  may  have  been  formed  in  the  lymph  or  chyle ; 
and  in  these  cases  they  are  probably  either  increasing  quickly  in  adap- 
tation to  quick  growth,  or  else  relatively  increasing  because,  through 
disease  or  defective  nutriment,  although  their  production  is  not  hin- 
dered, yet  their  development  into  the  perfect  red  blood-cells  cannot 
take  place.  But  I  believe  nothing  of  the  kind  happens  in  older  or  more 
healthy  frogs,  or  in  any  ordinary  inflammation  in  the.  warm-blooded 
animals.  I  have  drawn  blood  from  the  vessels  in  the  inflamed  bat's 
wing,  in  which  it  was  quite  stagnant,  and  have  found  not  more  than 
one  white  corpuscle  to  5000  red  ones.  I  have  often  examined  the 
human  blood  in  the  vessels  of  inflamed  parts  after  death,  and  have 
found  no  more  white  corpuscles  in  them  than  in  those  of  other  parts. 
In  blood  drawn  from  inflamed  parts  during  life,  I  have  found  only  the 
same  proportion  of  white  corpuscles  as  in  blood  from  the  healthy  parts 
of  the  same  person.  I  therefore  cannot  but  accord  with  the  opinion, 
often  expressed  by  Mr.  Wharton  Jones  and  Dr.  Hughes  Bennett,  that 
an  especial  abundance  of  white  corpuscles,  in  the  vessels  of  an  inflamed 
part,  is  neither  a  constant  nor  even  a  frequent  occurrence  ;  and  I  be- 
lieve that,  when  such  corpuscles  are  numerous  in  an  inflamed  part,  it  is 
only  when  they  are  abundant  in  the  whole  mass  of  the  blood.*  Now, 
as  already  stated,  they  are  thus  abundant  in  some  cases  of  inflamma- 
tion ;  especially,  I  think,  in  those  occurring  in  people  that  are  in  weak 
health,  and  in  the  tuberculous  ;  but,  even  in  these  cases,  I  have  never 
seen  an  instance  in  which  they  were  present  in  sufficient  quantity  to 
add  materially  to  the  obstruction  of  the  blood  in  the  inflamed  part,  nor 
one  in  which  any  influence  of  theirs  could  be  suspected  to  alter  pecu- 
liarly the  constitution  of  the  blood  therein. 

It  has  long  been  known  that  when  healthy  blood  is  received  on  a 
glass  plate,  and  immediately  examined  with  the  microscope,  the  cor- 
puscles may  be  seen  in  about  half  a  minute  to  run  together  into  piles, 
or  rouleaux,  which  arrange  themselves  in  a  small  meshed  network,  as 
in  the  adjoining  figure  (a),  (Fig.  32).  Mr.  Wharton  Jones  was  the  first 
to  point  out  that  if  a  drop  of  blood  of  a  patient  sufi'ering  from  acute 
rheumatism,  or  inflammation,  be  similarly  examined,  the  piles  of  cor- 
puscles are  formed  more  rapidly  and  run  more  closely  into  masses,  which 
have  large  spaces  between  them  (b).  By  this  arrangement  the  thin 
clot,  outspread  on  the  glass,  "has  the  peculiar  mottled  pink  and  white 
appearance  which  Mr.  Hunter  observed  as  one  of  the  characters  of  in- 

*  Dr.  Hughes  Bennett's  researches  on  Leucocythsemia  have  shown  that  even  the  ex- 
tremest  abundance  of  vt^hite  corpuscles  in  the  blood  has  no  tendency  either  to  produce  or  to 
aggravate  inflammations. 


STATE    OF    THE    BLOOD. 


223 


flammatory  blood.  The  same  condition  is  observed  in  the  blood  of 
pregnant  women,  and  appears  natural  in  that  of  horses  ;  and  in  all  these 
cases  it  may  be  regarded  as  the  chief  cause  of  the  formation  of  the  buffy 


coat,  inasmuch  as  the  clustered  blood-cells,  sinking  rapidly,  generally 
subside  to  some  distance  below  the  surface  of  the  liquid  part  of  the 
blood,  before  the  coagulation  of  the  fibrine  is  begun.  This  aggrega- 
tion of  the  corpuscles  does  not  appear  to  be  due,  as  was  at  one  time 
supposed,  to  an  increased  viscidity  of  the  liquor  sanguinis  owing  to  an 
excess  of  fibrine,  for  Lister's  observations  have  shown  that  they  aggre- 
gate quite  as  closely  after  the  removal  of  the  fibrine,  as  they  did  before. 
Some  have  supposed  that  a  similar  adhesion  of  the  blood-cells  may 
occur  in  the  vessels  of  an  inflamed  part,  and  produce  or  materially  affect 
the  inflammatory  process.  I  have  seen  nothing  of  the  kind  in  either 
the  inflamed  bat's  wing  or  in  the  vessels  of  inflamed  organs  examined 
after  death.  When  the  blood  is  not  stagnant  the  corpuscles  are  indeed 
closely  crowded,  but  they  are  not  clustered,  nor  do  they  appear  adhe- 
rent ;  neither  does  such  clustering  appear  even  in  stagnant  blood ;  the 
change  here  appears  to  be  a  diffusion  of  the  coloring  matter,  so  that  the 
outlines  of  individual  blood-cells  cannot  be  seen,  and  all  the  contents  of 
the  vessel  present  a  uniform  bright  carmine  tint.* 


*  The  adhesion  of  the  corpuscles  of  the  blood  to  each  other,  and  to  the  inner  surface  of 
the  walls  of  the  vessels  of  an  inflamed  part,  has  of  late  engaged  the  attention  of  patholo- 
gists. Mr.  Lister  has  especially  investigated  this  subject,  and  has  reached  several  very  im- 
portant conclusions.  In  the  vessels  of  a  healthy  part  neither  the  red  nor  white  corpuscles 
exhibit  any  tendency  to  adhesiveness.  When  the  part  is  irritated  or  inflamed,  both  kinds 
of  corpuscles  acquire  such  a  degree  of  adhesiveness  as  makes  them  stick  to  each  other  and 
to  the  walls  of  the  vessels,  and  it  is  through  this  that  the  stasis,  or  "  stagnation  of  blood"  in 
the  part,  is  occasioned.  Mr.  Lister,  however,  believes  that  the  amount  of  adhesion  in  these 
cases  is  never  greater  than  that  which  is  exhibited  by  the  corpuscles  taken  from  a  healthy 
part  when  examined  outside  the  body,  as  on  a  plate  of  glass.  So  long  therefore  as  the 
blood  flows  through  the  vessels  of  a  healthy  part,  no  adhesion  of  the  corpuscles,  either  to 
each  other  or  to  the  walls  of  the  vessels,  takes  place.     But  when,  through  the  application 


224  PHENOMENA    OF    INFLAMMATION: 

But  although  we  can  see  so  little  of  the  changes  that  may  ensue  in 
blood  thus  stagnant  or  much  retarded,  yet  we  may  he  nearly  sure  that 
the  blood  in  an  inflamed  part  does  undergo  important  changes,  when  we 
remember  what  general  effects,  what  constitutional  disturbance,  may 
ensue  in  the  train  of  an  inflammation  of  purely  local  origin.  Changes 
probably  ensue  in  the  blood  similar  to  some  of  those  that  we  shall  have 
to  trace  in  the  lymph  effused  from  it  into  the  parts  around  the  vessels 
particles  of  fibrine  may  coagulate  in  it,  and  corpuscles  like  those  of 
lymph  may  be  formed  and  degenerate  within  it ;  and  these,  when  the 
stagnation  is  not  constant,  or  is  incomplete,  or  is  passed  away,  may  be ; 
carried  into  the  general  circulation,  infecting  the  whole  blood,  exciting 
general  disturbance,  as  in  traumatic  fever,  or  producing  various  and 
wide-extended  suppurations,  as_  in  the  purulent  diathesis  following  local 
injury.  All  these,  and  many  other  concomitants  of  inflammation,  may 
be  reasonably  ascribed,  at  least  in  part,  to  the  changes  that  the  blood 
undergoes  in  the  inflamed  tissue  ;  but  I  must  repeat  that  nothing  that 
either  the  microscope  or  chemistry  has  yet  discerned  will  suffice  to  ex- 
plain these  changes ;  they  belong  rather  to  the  theory  than  to  the  facts 
of  inflammation. 

III.  The  third  enumerated  condition  for  the  healthy  nutrition  of  a 
part  is  a  certain  influence  of  the  nervous  force.  The  change  that  this 
undergoes  in  an  inflamed  part  is,  therefore,  next  to  be  considered  ;  or, 
rather,  the  evidence  that  it  is  changed  is  to  be  cited ;  for,  as  we  have  no 
exact  knowledge  of  the  manner  in  which  the  nervous  force  operates  in 
ordinary  nutrition,  so  neither  can  we  tell  how  its  operation  is  affected 
in  inflammation,  though  we  may  be  sure  that  it  is  not  normal. 

The  expression  that  the  nerves  of  an  inflamed  part  are  in  an  "  excited 
state,"  is  suggested  by  the  existence  of  pain  ;  by  a  slight  stimulus  being 
acutely  felt ;  by  the  natural  heat,  or  a  slight  increase  of  the  heat,  being 
felt  as  a  burning;  and  by  the  part  being,  even  independent  of  any 
known  stimulus,  the  seat  or  source  of  subjective  parns  and  heat.  But 
the  very  frequent  cases  in  which  pain  exists,  and  abides  long,  without 
any  other  sign  of  inflammation,  and  the  cases  in  which  the  pain  bears 
no  kind  of  proportion  to  those  other  signs,  or  to  the  effects  of  inflam- 
mation,— these  may  suggest  that,  besides  this  "excited"  state  of  the 
nervous  force,  which  is  felt  as  pain  in  the  inflamed  part,  there  may  be 

of  an  irritant,  the  healthy  state  of  the  tissues  is  changed,  then  they  assume  towards  the 
blood  the  relation  of  dead  or  inorganic  matter,  upon  which  adhesiveness  of  the  corpuscles 
occurs,  and  inflammatory  congestion  is  occasioned. 

Many  recent  experiments  on  the  frog's  web  (H.  Weber,  Miiller's  Archiv,  1853),  (Schuler, 
Wiirzburg  Verhandl.  B.  iv,  H.  iii) ;  (Gunning,  pamphlet,  Utrecht,  1857);  (Lister.  Phil. 
Trans.,  1858),  made,  either  after  tightly  applying  a  ligature  around  the  limb,  or  even  after 
amputation,  show  that  accumulation  of  corpuscles  may  be  produced  in  a  part  even  when 
cut  off  partially,  or  entirely,  from  the  rest  of  the  body,  by  the  application  of  the  various  irri- 
tants which  produce  it  in  the  perfect  limb.  Inflammatory  congestion  is,  therefore,  quite  in- 
dependent of  the  general  circulation. 


STATE     OF    THE    NERVE-FORCE.  225 

some  other  state  by  which  the  nervous  force  is  more  intimately  con- 
nected with  the  inflammatory  process  ;  a  state  of  disturbance  which 
may,  indeed,  be  felt  as  pain,  but  which  more  properly  affects  the  influ- 
ence of  the  nervous  force  in  the  process  of  nutrition. 

We  obtain  some  evidence  of  the  existence  of  such  a  state  in  the  fact, 
that,  without  relation  to  pain,  it  is  communicable  from  the  nerves  of  in- 
flamed parts  to  those  of  other  parts  ;  in  which  parts,  then,  a  kind  of 
sympathetic  inflammation  may  be  generated.  This  transference  or  com- 
munication of  the  disturbance  of  nervous  force  is,  indeed,  evident  enough 
in  relation  to  that  state  which  is  felt  as  pain  ;  for  pain  is  not  limited  to 
the  inflamed  part,  but  is  difi"used  around  it,  and  is,  in  sympathy,  often 
felt  where  no  other  sign  of  inflammation  exists.  But,  besides,  and  some- 
times, I  repeat,  independent  of  this  condition  which  is  felt  as  pain,  the 
inflammatory  condition,  if  I  may  so  name  it,  of  the  nervous  force,  may 
be  similarly  communicated  or  transferred.  The  simplest  may  be  the 
most  proving  instances.  Whoever  has  worked  much  with  microscopes 
may  have  been  conscious  of  some  amount  of  inflammation  of  the  con- 
junctiva, in  consequence  of  overwork.  Now,  the  stimulus  exciting  this 
inflammation  has  been  directly  applied  to  the  retina  alone ;  and  I  have 
often  had  a  slightly  inflamed  left  conjunctiva,  after  long  working  with 
the  right  eye,  while  the  left  eye  has  been  all  the  time  closed.  I  know 
not  how  such  an  inflammation  of  the  conjunctiva  can  be  explained,  ex- 
cept on  the  supposition  that  the  excited  state  of  the  optic  nerve  is  trans- 
ferred or  communicated  to  the  filaments  of  the  nerves  of  the  conjunctiva, 
generating  in  them  such  a  state  as  interferes  with  its  nutrition.  It  is 
true  that,  in  these  simpler  cases,  the  retina  is  not  itself  evidently  in- 
flamed ;  but  after  yet  severer  stimulus  it  commonly  is  so,  and  the  con- 
junctiva shares  in  the  evil  efi"ects  of  the  communicated  stimulus  ;  eff'ects 
which  we  cannot  ascribe  to  any  alteration  in  the  blood,  or  the  size  of 
the  bloodvessels. 

I  may  mention  another  case  ;  the  occurrence  of  inflammation  of  the 
testicle  in  cases  of  severe  irritation  of  the  urethra.  The  most  unexcep- 
tionable cases  of  the  kind  are  those  in  which  the  irritation  is  produced 
by  a  calculus  impacted  in  a  healthy  urethra.  I  have  a  specimen,*  in 
which  extensive  deposits  of  lymph  and  pus  are  seen  in  the  testicle  of  a 
man,  in  whose  urethra  a  portion  of  calculus  was  impacted  after  lithotrity. 
Here  is  such  an  inflammation  as  we  cannot  refer  to  disease  of  the  blood, 
and  attended  by  such  changes  as  we  cannot  explain  by  any  enlargement 
or  paralysis  of  the  bloodvessels  :  nor  do  I  know  how  it  can  be  at  all  ex- 
plained, except  by  the  disturbance  of  the  exercise  of  the  nervous  force 
in  the  testicle,  which  disturbance  was  excited  by  transference  from  the 
morbidly  affected  nerves  of  the  primary  seat  of  irritation  in  the  urethra. 

In  like  manner,  I  believe  that  the  extension  or  transference  of  in- 
flammation, after  or  with  pain,  may  be  ascribed,  at  least  in  part,  to  the 

*  Museum  of  St.  Bartholomew's  Hospital,  Ser.  xxviii,  No.  55. 


226  PHENOMENA    OF    INFLAMMATION. 

coincident  transference  of  the  disturbed  plasturgic  force  of  the  nervous 
system.  In  paroxysms  of  neuralgia,  we  see  sometimes  a  transient  in- 
flammatory redness  or  oedema  of  the  part ;  so,  when  a  more  abiding 
pain  has  been  excited,  by  sympathy  with  some  inflamed  part,  there  may 
presently  supervene  the  more  palpable  efiects  of  inflammation.* 

I  feel  that  in  discussing  such  a  point  as  this,  one  passes  from  the 
ground  of  demonstrable  facts  ;  but  there  is,  I  hope,  less  fault  in  this  than 
in  the  belief  that  the  very  little  we  can  see  of  a  morbid  process  can 
guide  us  to  its  whole  pathology.  When  we  look  at  an  inflamed  part,  we 
should  not  think  that,  if  we  could  see  its  bloodvessels  and  test  its  blood, 
we  should  detect  all  that  is  in  error  there :  rather,  we  should  think  that 
all  the  forces  are  at  fault  which  should  be  concurring  to  the  due  main- 
tenance of  that  part ;  and  while  we  are  ignorant  of  the  nature  of  some 
of  these  forces,  it  is  better  that  their  places  in  our  minds  should  be  oc- 
cupied by  reasonable  hypotheses,  than  that  they  should  be  left  blank, 
or  be  overspread  with  the  tinge  of  one  exaggerated  theory,  such  as  those 
are  which  ascribe  all  inflammation  to  a  change  in  some  one  of  the  con- 
ditions of  nutrition. 

IV.  The  last  condition  necessary  to  healthy  nutrition  in  a  part  is  the 
natural  or  healthy  state  of  the  part  itself. 

The  manner  in  which  this  is  changed  in  the  inflammatory  state  can- 
not be  well  considered  till  an  account  has  been  given  of  the  exudation 
that  takes  place  from  the  bloodvessels,  and  of  some  other  changes  in  the 
very  process  of  nutrition.  Let  it,  for  the  present,  suffice  to  say  (1), 
that  a  change  in  the  condition  of  a  part  involving  a  disturbance  in  the 
nutrition  of  the  proper  textural  elements,  may  be  the  cause,  indepen- 
dently of  bloodvessels  or  nerves,  of  an  inflammation  in  it,  as  in  wounds, 
lodgement  of  foreign  bodies,  and  other  injuries  of  non-vascular  and 
other  parts ;  and  (2)  that  when  an  inflammation  is  thus,  or  in  any  other 
way,  established,  the  proper  elements  of  the  aff"ected  part  continually 
sufler  change.  Such  changes  are  due,  first,  to  the  degenerations  which, 
as  in  other  cases  of  hindered  nutrition,  the  elemental  structures  spon- 
taneously undergo :  and,  secondly,  to  the  penetration  of  the  inflamma- 
tory product  into  them  and  the  interstices  between  them.  Each  of 
these  sources  of  change  may,  in  diff'erent  cases,  predominate  :  in  cer- 
tain cases,  it  is  probable  that  one  alone  of  them  may  be  eff"ective ;  and 
either  or  both  of  them  may  afi"ect  either  the  elemental  structures  that 
are  already  perfected,  or,  probably,  in  a  greater  degree,  the  materials 
that  are  in  progress  of  development. f 

*  In  the  second  lecture  the  effects  produced  upon  the  nutrition  of  a  part  by  the  division  or 
irritation  of  the  nerves  going  to  it,  has  been  discussed. 

f  At  this  place  it  may  not  be  amiss  to  advert  to  the  very  striking  experiments  of  Mr. 
Lister  (Phil.  Trans.  1858),  on  the  influence  exercised  by  irritants  on  the  pigment  cells  in 
the  frog's  web  and  on  the  movements  of  the  cilia,  which  indicate  that  an  impairment  in  the 
functional  activity  of  the  tissues  is  the  essential  occurrence  which  leads  to  inflammatory 
stasis  of  the  blood.     For  it  appears  that  all  agents  capable  of  causing  inflammatory  conges- 


PRODUCTS     OF    INFLAMMATION.  227 

All  these  things  will  be  subjects  of  future  lectures ;  but,  before  pro- 
ceeding to  them,  let  me  add  a  few  words,  to  prevent  misunderstanding. 

I  have  spoken  so  separately  of  the  changes  in  the  several  conditions 
of  nutrition,  that  I  may  have  seemed  to  imply  that  inflammation  may 
consist  in  the  disturbance  sometimes  of  one,  sometimes  of  another,  of 
these  states.  It  is  true  that  inflammation  may  have  its  beginning  in 
any  one  of  these  conditions.  Indeed  there  is  not  one  of  them  that  has 
not  been  made  the  cause  of  inflammation  by  some  one  who  has  looked 
at  the  subject  from  too  narrow  a  point  of  view, — as  in  an  alteration  of 
the  blood  in  rheumatism,  in  an  alteration  of  the  nervous  force  in  irri- 
tation of  the  retina,  in  an  alteration  of  the  proper  elements  of  the  tissue/ 
in  inflammation  of  the  cornea ;  but,  probably,  it  is  never  fully  estab- 
lished without  involving  in  error  all  the  conditions  of  nutrition  ;  and 
both  the  manner  in  which  they  may  be  thus  all  involved,  and  their  sub- 
sequent changes,  should  be  studied  as  concurrent  events,  rather  than 
as  a  series  of  events,  of  which  each  stands  in  the  relation  of  a  conse- 
quence to  one  or  more  of  those  that  preceded  it.  Nowhere  more  than 
here  is  the  mischief  evident,  of  trying  to  discern  in  the  economy  of  or- 
ganic beings  a  single  chain  or  series  of  events,  among  which  each  may 
appear  as  the  consequence  of  its  immediate  predecessor  :  most  fallacious 
is  the  supposition  that,  starting  from  a  turgescence  and  stagnation  of 
blood  in  the  vessels  of  a  part,  we  may  explain  the  pain,  the  swelling, 
the  heat,  and  all  the  other  early  and  consecutive  phenomena  of  inflam- 
mation. The  only  secure  mode  of  apprehending  the  truth  in  this,  as 
in  every  other  part  of  the  economy  of  living  beings,  is  by  studying  what 
we  can  observe  as  concurrent,  yet  often  independent,  phenomena,  or  as 
events  that  follow  in  a  constant,  but  not  necessarily  a  consequent,  order. 


LECTURE    XIV. 

PEODUCTS    OF   INFLAMMATION. 

The  state  described  in  the  last  lecture  may,  without  further  change, 
cease  and  pass  by,  and  leave  the  part,  apparently,  just  as  it  was  before. 

tion  when  applied  to  a  vascular  part,  produce,  by  their  direct  action  upon  the  tissues,  a  state 
quite  distinct  from  death,  in  which,  nevertheless,  the  powers  of  the  tissues  are  completely 
prostrated  for  the  time  being,  and  that  a  greater  or  less  degree  of  this  temporary  loss  of 
power  invariably  occurs  as  a  primary  effect  of  irritation  if  carried  sufficiently  far  to  induce 
any  inflammatory  congestion.  If  the  action  of  the  irritant  is  not  too  powerful,  or  if  its  ap- 
plication is  not  too  prolonged,  then  the  derangement  in  the  functions  of  the  textures  is  gradu- 
ally restored,  along  with,  and  apparently  as  a  consequence  of,  which  restoration,  the  vascu- 
lar congestion  terminates,  and  the  blood  flows  along  its  vessels  in  the  usual  manner.  These 
observations  on  the  state  of  the  tissues  are  in  complete  harmony  with  those  made  by  the 
same  author  upon  the  blood  corpuscles,  which,  as  stated  in  the  note  to  p.  223,  appear  to 
acquire  adhesiveness  in  an  irritated  part  in  consequence  of  the  affected  tissues  ceasing  to 
maintain  their  normal  vital  relations  to  the  blood. 


228  PRODUCTS     OF    INFLAMMATION: 

And  there  are  two  chief  modes  in  which  this  may  happen  ;  namelj, 
by  resolution  or  the  simple  cessation  of  the  inflammation,  and  by  me- 
tastasis, in  which,  while  the  inflammation  disappears  from  one  part,  it 
appears  in  another.  So  far  as  the  inflamed  part  itself  is  concerned,  I 
believe  the  changes  are  in  both  these  cases  the  same,  and  consist  in  a 
more  or  less  speedy  return  to  the  normal  method  of  circulation,  and 
the  normal  apparent  condition  of  the  blood  and  of  the  nerves ;  the  tis- 
sue itself  presenting  no  change  of  structure. 

I  do  not  know  that  any  description  of  the  process  of  recovery,  from 
the  inflammatory  state,  would  tell  more  than  is  implied  by  calling  it  a 
gradual  return  to  the  natural  state,  a  gradual  retracing  of  the  steps  by 
which  the  natural  actions  had  been  departed  from.  As  it  has  been 
watched  in  the  frog's  web,  and  in  the  bat's  wing,  the  vessels,  that  were 
filled  with  quick -flowing  blood,  become  narrower,  the  streams  in  them 
also  becoming  slower,  and  less  gorged  with  red  blood-corpuscles,  till  the 
natural  state  is  restored.  The  pulsating  or  slower  streams  are  equal- 
ized with  those  about  them,  and,  gradually  making  their  way  into  the 
stagnant  columns,  drive  them  on  or  disperse  them.  In  the  frog,  clus- 
ters of  blood-corpuscles  have  been  seen  to  become  detached,  by  a 
stream  breaking  ofi"  portions  of  the  stagnant  blood,  and  then  to  float 
into  the  current,  where,  gradually,  they  disperse.  So,  too,  in  the  tad- 
pole, after  injury,  I  have  seen  fragments  of  fibrine,  washed  from  the 
blood  in  the  vessels  of  the  injured  part,  floating  in  some  distant  vessels. 
Yirchow's  and  Kirkes's  observations  leave  no  doubt  that  similar  changes 
may  occur  in  the  warm-blooded  animals,  and  may  be  the  source  of  great 
evil  by  carrying  the  materials  of  diseased  or  degenerate  blood  from  a 
diseased  organ  to  one  that  was  previously  healthy  (p.  116). 

It  may  be  difficult  to  explain  this  recovery  in  the  case  of  complicated 
inflammations.  When  a  slight  mechanical  stimulus  has  been  applied, 
and  the  vessels,  after  contracting,  have  dilated,  we  may  see  some  signs 
of  weakened  muscular  power,  in  the  fact  that  the  same  stimulus  will 
not  make  them  contract  again ;  and  then  their  gradual  recovery  may 
be  the  consequence  of  their  regaining  their  weakened  and  exhausted 
power,  just  as  a  wearied  muscle  does  when  left  at  rest.  This  must 
always  be  one  element  in  the  recovery  of  the  natural  state,  by  a  part 
that  has  been  inflamed ;  indeed,  it  is  probably  that  part  of  recovery 
which  is  most  slowly  achieved.  Still,  it  is,  probably,  only  one  ele- 
ment in  the  process  of  recovery.  In  an  inflammation  in  which  all  the 
conditions  of  nutrition  are  at  fault,  each  must  recover  its  normal  state ; 
but,  of  the  manner  in  which  they  severally  do  so,  we  have  no  know- 
ledge. The  order  in  which  they  are  restored  is  scarcely  less  uncertain  ; 
probably  it  is  not  constant,  but  may  depend,  in  great  measure,  on  the 
order  in  which  they  were  involved  in  error.  But  we  have  no  clear 
facts  in  this  matter  ;  only  we  may  observe,  that  in  many  cases,  if  we 
correct  the  error  of  one  of  the  conditions  of  nutrition,  the  rest  will  be 
more  apt  to  correct  themselves.     Thus,  of  the  remedies  for  inflamma- 


SERUM.  229 

tion,  few  can  act  upon  more  than  one  of  the  conditions  on  which  it  de- 
pends ;  yet  they  may  be  remedies  for  the  whole  disease  ;  for,  as  it  were, 
by  abstracting  one  of  its  elements,  they  destroy  the  consistence  and 
mutual  tenure  of  the  rest. 

The  cessation  of  the  disease  may  be  regarded  as  the  most  perfect 
cure  of  which  inflammation  admits.  It  is  in  many  cases  an  unalloyed 
advantage  ;  but  in  some  it  is  not  so,  though  the  local  change  may  be 
the  same ;  for  materials  accumulated  in  the  stagnant  blood  of  the  in- 
flamed part,  or  absorbed  from  its  morbidly  altered  tissues,  may,  when 
the  inflammation  subsides,  pass  into  the  general  current  of  the  blood, 
and  infect  its  whole  mass,  or  disturb  the  nutrition  of  an  organ  more  im- 
portant than  that  which  they  have  left.  Such  are  the  events  of  the 
metastasis  of  gout,  and  the  premature  subsidence  of  cutaneous  erup- 
tions. 

We  have  now  considered  how,  in  the  inflammatory  state,  the  con- 
ditions of  nutrition  are  affected  :  and,  in  a  future  lecture,  I  hope  to 
show  how  a  change  in  any  one  of  these  conditions  may  appear  as  the 
cause  of  inflammation,  by  being  the  first  in  the  series  of  changes,  in 
which,  in  the  complete  morbid  process,  they  are  all  involved. 

The  next  subject  may  be  the  changes  in  the  nutritive  process  itself; 
those  which  are  commonly  observed  as  the  effects  of  inflammation, 
when  the  process  does  not  subside  in  the  manner  just  described.  They 
are  chiefly  manifest  (1)  in  a  change  of  the  material  that  is  separated  from 
the  blood  into  or  upon  the  affected  tissue ;  and  (2)  in  changes  of  the 
tissue  itself.  These  changes  usually  coincide  :  and  it  may  be  generally 
said,  that  in  all  inflammations,  at  least  of  vascular  parts,  there  is  at 
once  an  increased  exudation  of  fluid  from  the  bloodvessels,  and  a  dete- 
rioration of  the  structures,  of  the  affected  part.  Either  of  these  events 
may,  in  certain  cases,  predominate  over  the  other ;  in  some  instances, 
one  alone  of  them  may  be  observed ;  but  they  so  generally  concur,  that 
a  natural  division  of  the  inflammatory  changes  of  the  nutritive  process 
may  be  into  those  that  Sbre  productive  and  those  that  are  destructive. 

Adopting,  then,  such  a  division,  as  of  the  effects  of  inflammation, 
the  description  of  the  productive  changes  will  include  the  histories  of 
the  several  effusions  or  exudations  from  the  bloodvessels  into  the  in- 
flamed part,  their  developments,  degenerations,  and  other  changes. 
In  the  account  of  the  destructive  effects  may  be  comprised  that  of  the 
various  defects  of  nutrition,  the  degeneration,  absorption,  ulceration, 
and  death,  to  which  the  proper  elements  of  the  inflamed  part,  and,  with 
them,  the  products  of  the  inflammation,  are  liable. 

I  proceed,  then,  to  these  histories ;  and  first  of  the  products  of  in- 
flammation or  inflammatory  exudations. 

The  materials  that  may  be  effused  from  the  bloodvessels  of  inflamed 
parts  are  chiefly  these :  serum ;  blood  ;  lymph,  or  inflammatory  exuda- 
tion especially  so  called  ;  and  mucus.     The  last  two  may  be  regarded 


230  PRODUCTS    OF    INFLAMMATION: 

as  primary  forms,  from  which,  by  development,  or  degeneration,  many 
others  may  be  derived. 

I.  The  effusion  of  serum,  except  as  the  result  of  the  lowest  degrees  of 
inflammation,  or  as  a  diluent  of  other  products,  is  probably  a  rare 
event.  That  which  is  usually  regarded  as  a  serous  effusion  in  inflam- 
mation, is,  in  many  cases,  a  fluid  that  contains  fibrine  or  a  fibrogenous 
substance,  which  coagulates  on  exposure  to  the  air  and  resembles  the 
liquor  sanguinis  rather  than  mere  serum.  It  is  this  kind  of  effusion  on 
which  Vogel*  has  fully  written,  under  the  designation  of  "Hydrops 
fibrinosus."  A  good  example  of  it  may  be  seen  in  the  fluid  contained 
in  blisters,  raised  by  the  action  of  cantharides  or  heat  applied  to  healthy 
persons.  And  another  form  of  liquid  effusion  differs  from  serum,  in 
that,  though  it  does  not  coagulate,  it  contains  a  material  capable  of 
organization  into  cells :  such  is  the  fluid  that  fills  the  early  vesicles  of 
herpes,  eczema,  and  some  other  cutaneous  diseases. 

The  fluid  that  contains  fibrine,  and  is  most  generally  described  as  a 
serous  effusion,  may  have  the  ordinary  aspect  of  serum  ;  more  rarely 
it  is  colorless  or  opalescent,  like  the  liquid  part  of  the  blood  which  one 
sees  collecting  for  the  formation  of  a  buffy  coat.  The  fibrine  that  it 
contains  may  remain  in  solution,  or  without  coagulation,  for  an  indefi- 
nite time  within  the  body,  but  will  coagulate  readily  when  withdrawn. 
For  example,  the  so-called  serous  effusion  which  is  abundant  in  the  in- 
teguments near  the  seat  of  an  acute  inflammation  in  deeper  parts,  and 
which  flows  out  like  a  thin  yellowish  serum,  after  death,  will  soon  form 
a  soft,  jelly-like  clot,  that  is  made  succulent  with  the  serum  soaked  in 
it.  The  fibrine  appears  tough,  opaque-white,  and  stringy,  when  the 
fluid  is  expressed  from  it,  and  shows  all  the  recognized  characters  of 
the  fibrine  of  the  blood.  Thus,  to  mention  but  one  case,  which  was  re- 
markable for  the  delay  of  the  coagulation.  A  man  received  a  com- 
pound fracture  of  the  leg,  and  it  was  followed  by  phlegmonous  inflam- 
mation and  abscesses  up  the  limb.  As  soon  as  the  inflammation  had 
subsided  enough,  the  limb  was  amputated  ;  and,  three  days  afterwards, 
in  examining  it,  a  quantity  of  serous-looking  fluid  oozed  from  the  cut 
through  the  integument.  I  collected  some  of  this,  and,  after  four  hours, 
it  formed  a  perfect  fibrinous  clot ;  yet  the  fibrine  in  this  case  had  re- 
mained among  the  tissues  without  coagulating,  for  three  days  after  the 
death  of  the  limb  and  for  many  more  days  during  the  life  of  the  patient. 

Such,  too,  are  the  effusions  like  serum  in  blisters  raised  on  the  skin 
by  heat  or  cantharides ;  such  the  serous  effusions  of  peritonitis,  as  in 
hernia,  and  of  many  cases  of  pleurisy  and  pericarditis.  All  these  fluids, 
though  they  may  retain  their  fluidity  for  weeks  or  months  within  the 
body,  during  life,  may  yet  coagulate  when  they  are  removed  from  the 
body.  With  these,  too,  may  be  reckoned,  but  as  the  most  neai'ly  serous 
of  the  class,  the  fluid  of  common  hydrocele  ;  for  I  have  seen  a  small 

*  Pathologische  Anatomie,  p.  23. 


SEKUM.  231 

coagulum  form  in  such  fluid  spontaneouslj  ;  and  the  presence  of  fibrine 
may  always  be  proved  by  the  formation  of  a  clot  when  a  small  piece  of 
blood-clot,  or  of  some  organized  tissue,  is  introduced  into  the  fluid. 

One  can  rarely  tell  why  the  coagulation  of  the  fibrine  in  these  cases 
should  be  delayed ;  there  are,  here,  the  same  difficulties  as  are  in  all 
the  exceptions  from  the  general  rules  of  the  coagulation  of  the  blood. 
But,  it  may  be  observed,  the  delay  of  the  coagulation  is  a  propitious 
event  in  all  these  cases  ;  for,  so  long  as  the  efi'usion  is  liquid,  absorp- 
tion may  ensue  on  the  subsidence  of  the  inflammation;  but  absorption 
is  more  unlikely  and  tardy  when  the  fibrine  has  coagulated.  Thus, 
large  quantities  of  fluid,  which,  we  may  be  sure,  contained  fibrine,  may 
disappear  by  absorption  from  the  seats  of  acute  rheumatism  or  gout, 
or  from  the  pleura  or  peritoneum,  or  from  the  subcutaneous  tissues,  and 
leave  only  inconsiderable  adhesion,  or  thickening  of  the  afiected  part. 
But,  on  the  other  hand,  when,  in  the  same  class  of  cases,  the  fibrine 
coagulates,  it  may  be  organized,  and  the  usual  consequent  phenomena 
of  inflammation  will  ensue.  Thus  it  is  in  the  cases  of  what  has  been 
called  solid  oedema,  where,  in  the  neighborhood  of  acute  inflamma- 
tion, an  efiusion  long  abides  with  all  the  characters  of  ordinary  serous 
oedema ;  but,  at  length,  the  tissues  are  found  indurated  and  adhering, 
the  oedema  having  consisted  in  the  efi'usion  of  serum  with  fibrine,  which 
has  coagulated  and  becomes  organized  in  the  seats  of  its  efiusion.  Thus, 
too,  it  is  that  the  damage  done  by  rheumatism  in  a  part  is,  on  the  whole, 
in  direct  proportion  to  the  length  of  time  it  has  subsisted  there,  and  the 
opportunity  given  by  time  for  the  coagulation  of  the  fibrine. 

From  what  I  have  said,  it  will  appear  that  nearly  all  of  what  are 
called  serous  eff"usions  in  inflammation  are  efi'usions  of  fluid  containing 
either  fibrine,  or  a  material  that  will  organize  itself  into  cells.  But  it 
may  be  said  that  we  often  find,  after  death,  efi'usions  which  contain 
nothing  but  the  constituents  of  serum,  though  produced  in  an  inflamma- 
tory process.  If,  however,  we  examine  these  cases  more  closely,  they 
will  appear  consistent  with  the  others  :  some  of  the  fluids  will  coagu- 
late if  kept  for  several  hours,  or  if  mixed  with  other  serous  fluids,  or  if 
fragments  of  fibrine  be  placed  in  them  ;  in  others  we  find  fiakes  of 
molecular  matter,  indicating  that  fibrine  had  been  already  coagulated, 
or  that  corpuscles  had  been  formed,  but  that  subsequently  they  were 
disintegrated,  or  even  partially  dissolved;  and  in  some  we  may  believe 
that  similar  materials  were  decomposed  in  the  last  periods  of  life,  or 
after  death. 

On  the  whole,  it  seems  sure  that  an  efi'usion  of  serum  alone  is  a  rare 
efi'ect  of  inflammation,  and  that  generally  it  is  characteristic  of  only  the 
lowest  degrees  of  the  disease.  Among  the  instances  of  it  are,  probably, 
the  cases  of  the  chronic  forms  of  hydrops  articuli,  some  forms  of  hydro- 
cephalus, and  some  cases  of  inflammatory  oedema  of  the  mucous  mem- 
brane, as  in  the  oedema  of  the  glottis,  and  chemosis  of  the  conjunctiva. 

In  the  nearly  constant  fact  of  the  presence  of  organizable  materials 


232  PRODUCTS    OF    INFLAMMATION: 

in  the  products  of  inflammation,  we  have  one  evidence  of  the  likeness 
between  inflammation  and  the  normal  process  of  nutrition,  and  of  its 
difi'erence  from  the  merely  mechanical  obstructions  or  stagnations  of  the 
blood.  In  these,  the  material  efi"used  from  the  blood  is  usually  the 
merely  serous  part :  the  fluids  of  anasarca  and  ascites  will  not  coagu- 
late ;  they  present  neither  fibrine  nor  corpuscles,  except  in  the  cases  of 
extremest  obstruction,  when,  as  in  cases  of  ascites  from  advanced  disease 
of  the  heart,  one  may  find  flakes  of  fibrine  floating  in  the  abdomen,  or 
masses  of  it  soaked  and  swollen  up  with  serum.* 

II.  The  second  of  the  so-called  inflammatory  efi"usions  is  Blood. 

Among  the  effusions  of  blood  that  occur  in  connection  with  the  inflam- 
matory process,  many,  as  Rokitansky  has  explained,  are  examples  of 
hemorrhage  from  rupture  of  the  vessels  of  lymph  recently  become  vascu- 
lar. The  new  vessels,  or  their  rudiments,  are  peculiarly  delicate ;  and 
being  apt  to  rend,  like  the  vessels  of  new  granulations,  with  a  very 
slight  force,  especially  when  they  are  made  turgid  or  dilated  by  an 
attack  of  inflammation  of  the  lymph,  they  will  commonly  be  sources  of 
considerable  bleeding.  So,  for  example,  it  probably  sometimes  happens 
when,  as  the  expression  is,  a  hydrocele  is  converted  into  a  hsematocele ; 
some  lymph  becoming  vascular,  and  being  submitted  to  even  slight  vio- 
lence, its  vessels  break,  and  blood  is  poured  into  the  sac.  So,  too,  pro- 
bably, it  is  with  many  or  all  the  cases  of  what  are  called  hemorrhagic 
pericarditis.  But  of  these,  which  may  be  called  secondary  hemorrhages^ 
I  will  speak  hereafter. 

Primary  efiusions  of  blood,  i.  e.  efi"usions  of  blood  poured  from  the 
ruptured  vessels  of  the  inflamed  part,  and  mingled  with  the  lymph  or 
other  inflammatory  product,  appear  to  be  rare  in  some  forms  or  locali- 
ties of  inflammation,  but  are  almost  constant  in  others.  Thus,  e.g.  in 
pneumonia,  extravasated  blood-corpuscles  give  the  sputa  their  charac- 
teristic rusty  tinge.  In  the  inflammatory  red  softening  of  the  brain, 
blood  is  also  commonly  effused ;  and  the  condition  of  the  vessels,  which  I 
described  in  the  last  lecture  (p.  212),  may  well  account  for  their  rupture. 
There  are  also  other  cases  of  these  efi"usions  of  blood  in  inflammation : 
but  I  believe  these  imply  no  more  than  accidents  of  the  disease. 

We  must  not  confound  with  hemorrhages  the  cases  in  which  the  in- 
flammatory products  are  merely  blood-stained,  i.  e.,  have  acquired  a 
more  or  less  deep  tinge  of  blood  through  the  oozing  of  some  dissolved 

*  It  has  been  supposed  that,  in  mechanical  dropsies,  the  effusion  of  serum  takes  place 
through  the  walls  of  the  small  veins,  and  that  in  inflammations  an  equally  mechanical  effu- 
sion of  liquor  sanguinis  takes  place  through  the  walls  of  the  capillaries  and  small  arteries; 
and  this  supposition  is  assumed  for  an  explanation  of  the  difference  between  a  dropsical  and 
an  inflammatory  effusion.  But  I  think  that,  in  a  merely  mechanical  obstruction  of  the  blood, 
as  by  disease  of  the  heart,  or  compression  of  veins,  the  pressure  of  the  blood  cannot  but  be 
increased  alike  in  the  veins,  capillaries,  and  arteries,  and  that,  in  correspondence  with  this 
uniformly  diffused  pressure,  the  increased  effusion  will  take  place  at  once  through  all  these 
vessels,  in  direct  proportion  to  the  permeability  of  their  walls. 


LYMPH.  233 

coloring  matter  of  the  blood.  The  natui-al  color  of  inflammatory  exu- 
dations is  grayish  or  yellowish-white,  and,  even  when  they  have  become 
vascular,  their  opacity  in  the  recent  state  prevents  their  having  any 
uniform  tint  of  redness  visible  to  the  naked  eye.  When  inflammatory 
products  present  the  tinge  of  redness,  it  is  either  because  of  hemorrhage 
into  them,  or  because  they  have  imbibed  the  dissolved  coloring  matter 
of  the  blood ;  and  when  this  imbibition  happens  during  life,  or  soon 
after  death,  it  is  important,  as  implying  a  cachectic,  ill-maintained  con- 
dition of  the  blood,  in  which  condition  the  coloring  matter  of  the  cor- 
puscles becomes  unnaturally  soluble.  Thus,  blood-stained  effusions  are 
among  the  evil  signs  of  the  products  of  inflammation  during  typhus  and 
other  low  eruptive  fevers,  in  syphilis,  and  in  scurvy. 

III.  Serous  effusions,  then,  appear  to  be  rare  as  the  results  of  in- 
flammation, and  eff'usions  of  blood  are  but  accidents  in  its  course.  The 
characteristic  primary  product  of  the  inflammatory  process  is  the  liquid 
which  the  elder  writers  named  "lymph,"  "coagulating  or  coagulable 
lymph,"  and  which  more  lately  has  been  called  "  exudation,"  or  "  in- 
flammatory exudation."*  It  is,  probably  always,  at  its  first  exudation 
a  pellucid  liquid,  which  passes  through  the  bloodvessels,  especially  the 
capillaries  of  the  inflamed  part,  or,  perhaps,  only  from  them  ;f  and  its 
most  characteristic  general  properties  are,  that  it  is  capable  of  organiza- 
tion even  while  its  external  circumstances  remain  apparently  the  same, 
and  that,  thus  organized,  it  may  proceed  by  development  to  the  con- 
struction of  tissues  like  the  natural  structures  of  the  body. 

The  form  assumed  by  inflammatory  lymph  in  its  primary  organiza- 
tion is  not  always  the  same.  There  are,  rather,  two  chief  forms  of  or- 
ganization, which,  though  they  are  often  seen  mixed  in  the  same  mate- 
rial, are  yet  so  distinct  as  to  warrant  the  speaking  of  two  varieties  of 
inflammatory  lymph  by  the  names  of  fibrinous  and  corpuscular.X 

To  the  fibrinous  variety  belong,  as  typical  examples,  all  the  instances 
in  which  inflammatory  lymph,  effused  as  a  liquid,  coagulates  into  the 
solid  form  and  yields,  when  the  fluid  is  pressed  from  the  solid  part, 
either  an  opaque  whitish,   elastic  substance,  having  the  general  pro- 

*  It  is  to  be  regretted  that  we  have  no  distinct  appellation  for  this  substance.  To  call  it 
"  lymph''  is  objectionable,  while,  already,  the  same  word  is  employed  for  the  fluid  in  the 
lymphatic  vessels,  with  which  it  is  probably  not  identical,  though  they  are  in  many  respects 
similar.  And  the  term  "exudation"  is  yet  more  objectionable,  since  it  has  to  be  employed 
as  well  for  the  act  of  separation  from  the  blood  as  for  the  material  separated ;  or,  even  if 
it  be  limited,  as  the  Germanized  "  Exsudat"  is,  to  what  has  oozed  from  the  blood,  still,  it  is 
equally  applicable  to  all  the  liquid  products  of  inflammation,  and  not  more  to  any  one  of 
them  than  to  the  serum  of  a  dropsy,  or  the  material  separated  for  normal  nutrition.  On  the 
whole,  in  accordance  with  the  generally  good  rule  of  retaining  an  old  term  till  a  better  new 
one  is  proposed,  the  words  "  inflammatory  lymph"  appear  least  improper. 

t  See  a  remarkable  case  by  Mr.  Bowman ;  Lectures  on  the  Eye,  p.  44. 

X  Corresponding  varieties  are  distinguished  or  implied  by  Vogel,  p.  30,  Dr.  Andrew  Clark 
(Medical  Gazette,  vol.  xliii,  p.  286),  and  others. 

16 


234  PRODUCTS   OF   inflammation: 

perties  of  the  fibrine  of  the  clot  of  blood,  or  _  the  softer,  and,  as  it  is 
supposed,  the  less  perfect  or  less  developed  fibrine  of  the  chyle  or  the 
absorbed  lymph. 

Such  examples  of  nearly  pure  fibrinous  inflammatory  lymph  are 
found,  in  the  cases  already  referred  to,  among  what  have  been  supposed 
to  be  efl'usions  of  mere  serum.  Such  are  many  instances  of  effusions 
produced  by  blisters  and  other  local  irritations  of  the  skin  in  healthy 
men:  such,  too,  are  most  of  the  efl'usions  in  acute  inflammations  of 
serous  membranes,  especially  in  those  of  traumatic  origin,  and  in  those 
that  occur  in  vigorous  men.  If  in  any  of  these  cases  the  lymph  be 
examined  after  coagulation,  it  may  be  hard  to  distinguish  it  from  the 
-fibrine  of  the  clot  of  blood.  The  layers  of  fibrinous  lymph  thus  formed 
may  be  known  to  the  naked  eye,  when  on  serous  membranes,  by  their 
peculiar  elasticity  and  toughness,  their  compact  and  often  laminated 
structure,  their  grayish  or  yellowish-white  and  semi-transparent  aspect, 
and  their  close  adhesion  to  the  membrane  even  before  they  have  become 
vascular. 

In  the  corpuscular  variety  of  inflammatory  lymph  no  coagulation,  in 
the  ordinary  sense  of  the  word,  takes  place ;  but  corpuscles  form  and 
float  free  in  the  liquid  part.  Typical  examples  of  this  variety  are  found 
in  the  early-formed  contents  of  the  vesicles  of  herpes,  eczema,  pemphi- 
gus, and  vaccinia ;  in  the  fluid  of  blisters  raised  in  cachectic  patients ; 
in  some  instances  of  pneumonia  ;  and  in  some  forms  of  inflammation  of 
serous  membrane. 

The  lymph,  or  exudation-corpuscles  or  cells,  found  in  such  lymph  as 
this,  present  numerous  varieties  in  their  several  developments  and  de- 
generations ;  but  in  their  first  appearance  resemble  .very  nearly  the 
primordial  condition  of  the  corpuscles  of  chyle  and  absorbed  lymph, 
the  white  corpuscles  of  the  blood,  and  those  of  granulations.* 

The  first  discernible  organic  form  in  the  lymph  of  herpes,  for  example, 
is  that  of  a  mass  of  soft,  colorless,  or  grayish-white  substance,  about 
55'oijth  of  an  inch  in  diameter,  round  or  oval,  pellucid,  but  appearing, 
as  if  through  irregularities  of  its  surface,  dimly  nebulous  or  wrinkled. 
It  does  not  look  granular,  nor  is  it  formed  by  an  aggregation  of  gra- 
nules ;  nor,  in  its  earliest  state,  can  any  cell-wall  be  clearly  demon- 
strated, or  any  nucleus,  on  adding  water.  But,  in  a  few  hours,  as  the 
development  of  this  cell-germ  proceeds,  a  pellucid  membrane  appears  to 
form  as  a  cell-wall  over  its  whole  surface  ;  and  now,  when  water  is  added, 
it  penetrates  this  membrane,  raising  up  part  of  it  like  a  clear  vesicle, 

*  I  have  already  (p.  141)  referred  to  this  fact  of  a  single  primordial  form  existing  in  tlie 
rudiments  of  many  structures,  which  in  later  periods  of  their  existence  are  widely  different. 
It  is  a  repetition  of  a  fact  in  the  first  development  of  beings.  In  the  early  embryo,  the 
most  ultimate  forms  are  developed  from  a  nearly  uniform  mass  of  primordial  embryo  or 
germ-cells.  And  so  it  is  in  later  life ;  many  of  both  the  normal  and  the  morbid  structures 
start  from  one  primordial  form,  and,  thence  proceeding,  diverge  more  and  more  widely  in 
attaining  their  several  perfect  shapes. 


LYMPH.  235 

while  upon  the  other  part  the  mass  retreats,  or  subsides,  and  appears 
more  nebulous  or  grumous  than  before.  In  yet  another  state,  which 
appears  to  be  a  later  stage  of  development,  the  action  of  water  not  only 
raises  up  a  cell-wall,  but  breaks  up  and  disperses  the  outer  part  of  the 
contents  of  the  cell,  and  exposes  in  the  interior  a  nucleus  which  is  com- 
monly round,  clearly  defined,  pellucid,  and  attached  to  the  cell-wall.* 

From  the  various  developments  of  these  cells  are  derived,  in  the  pro- 
ducts of  inflammation,  all  the  several  forms  of  corpuscles  that  are  de- 
scribed as  plastic  cells,  fibro-cells,  caudate  or  fibro-plastic  cells,  and  some 
forms  of  filaments.  These  correspond  with  the  development  of  granula- 
tion-cells, already  described  (p.  140).  On  the  other  hand,  from  their 
various  degenerations,  descend  those  known  as  pus-corpuscles,  granule- 
cells,  granule-masses,  inflammatory  globules,  and  much  of  the  molecular 
and  debris-like  matter  that  makes  inflammatory  efi'usions  turbid. 

The  examples  of  inflammatory  lymph  which  I  have  quoted  are  such 
as  may  be  considered  typical  of  the  two  varieties :  the  first,  in  which, 
spontaneously  coagulating,  it  presents  fibrine,  either  alone  or  mingled 
with  very  few  corpuscles  ;  and  the  second,  in  w^hich  corpuscles  are  found 
alone,  or  with  only  a  few  flakes  of  fibrine.  But,  in  a  large  number  of 
examples  of  inflammatory  lymph,  the  fibrine  and  the  corpuscles  occur 
together,  mixed  in  various  proportions,  the  one  or  the  other  preponde- 
rating. Such  instances  of  mixed  lymph  are  found  in  the  fluid  of  blisters 
in  all  persons  not  in  full  health ;  in  all  but  the  freshest  inflammations  of 
serous  membranes ;  in  most  of  the  inflammatory  deposits  in  cellular 
tissue,  and  in  most  of  the  viscera ;  and  in  the  false  membranes  of  croup 
and  other  similar  inflammations  of  mucous  membranes. 

Now,  in  general,  and  in  the  first  instance,  the  proportions  of  fibrine 
and  of  corpuscles  that  are  present  in  the  lymph  of  an  inflammation,  will 
determine  the  probability  of  its  being  organized,  or  of  its  degenerating. 
The  larger  the  proportion  of  fibrine  in  any  specimen  of  inflammatory 
lymph  (provided  it  be  healthy  fibrine),  the  greater  is  the  probability  of 
its  being  organized  into  tissue  ;  such  as  that  of  adhesions,  indurations, 
and  the  like.  On  the  other  hand,  supposing  the  other  conditions  for 
development  or  degeneration  to  be  the  same,  the  larger  the  proportion 
of  corpuscles  in  lymph,  the  greater  is  the  probability  of  suppuration  or 
some  other  degenerative  process,  and  the  more  tardy  is  any  process  of 
development  into  tissue.  In  other  words,  the  preponderance  of  fibrine 
in  the  lymph  is  generally  characteristic  of  the  "adhesive  inflamma- 
tion;" the  preponderance  of  corpuscles,  or  their  sole  existence,  in  the 
liquid,  is  a  general  feature  of  the  "  suppurative  inflammation."! 

*  It  may  be  that  the  cell-forms  met  with  in  the  fluid  of  herpes,  and  other  vesicular  erup- 
tions, are  developed  from  the  nuclei,  or  immature  cells  of  the  deeper  layers  of  the  epidermis, 
which,  owing  to  the  separation  and  elevation  of  the.  superficial  cuticular  layers  during  the 
vesicular  formation,  become  detached,  and  float  freely  in  the  fluid. 

t  In  this  view,  the  fibrinous  and  the  corpuscular  varieties  of  lymph  nearly  correspond 
with  those  which  Dr.  Williams,  in  his  Principles  of  Medicine,  and  others,  have  named  plas- 
tic and  aplastic  ;   but  they  do  not  completely  do  so.     In  ditferent  instances  of  both  varieties, 


236  PKODUCTS   OF  inflammation: 

The  knowledge  of  this  fact  may  help  us  to  learn  the  several  condi- 
tions on  -which,  in  the  first  instance,  depend  these  two  forms  of  inflam- 
mation, the  contrast  between  which  has  lost  none  of  its  importance 
since  the  time  of  Hunter.  I  will  therefore  at  once  enter  on  this  ques- 
tion,  what  are  the   conditions  that  determine  the  production  of  one 

or  the  other  variety  of  lymph  ;  the  fibrinous,  which,  apt  for  development, 
is  as  the  symbol  of  the  adhesive  inflammation,  or  the  corpuscular, 
which,  prone  to  degenerate,  may  be  that  of  the  suppurative  inflam- 
mation ? 

The  conditions  which  are  chiefly  powerful  in  determining  the  character 
and  tendency  of  inflammatory  lymph  are  three  ;  namely, — 

1.  The  state  of  the  blood  ; 

2.  The  seat  of  the  inflammation ; 

3.  The  degree  of  the  inflammation. 

First,  in  regard  to  the  influence  of  the  state  of  the  blood  in  deter- 
mining the  characters  of  an  inflammatory  product,  Rokitansky  has 
happily  expressed  it  by  saying  that  "  the  product  of  the  inflammation 
exists,  at  least  in  part,  in  its  germ  preformed  in  the  whole  blood." 
Some,  indeed,  have  supposed  that  lymph  is  only  the  liquor  sanguinis 
exuded  in  excess  through  the  walls  of  the  bloodvessels ;  but  of  this 
opinion  we  cannot  be  sure,  and  many  facts,  such  as  the  occurrence  of 
inflammatory  lymph  which  does  not  spontaneously  coagulate,  e.  g.  in 
herpes,  will  not  agree  with  it.  Still,  it  is  not  difiicult  to  show  that  a 
certain  character  is  commonly  impressed  by  the  state  of  the  blood  on 
the  inflammatory  product  from  it.* 

I  will  not  refer  here  to  the  cases  of  inoculable  diseases,  in  which  some 
of  the  morbid  material  that  was  in  the  blood  may  be  incorporated  with 
the  product  of  a  local  inflammation,  though  in  these  the  correspondence 
of  the  blood  and  the  inflammatory  product  is  manifest  enough ;  but  I 
will  refer  to  cases  that  may  show  a  more  general  correspondence  be- 
tween the  two,  a  correspondence  such  that,  according  to  the  state  of 

very  diverse  degrees  of  plastic  property  may  be  found  ;  and  the  occurrence  of  development 
or  degeneration  depends  on  many  things  besides  the  primary  characters  of  lymph.  They 
more  nearly  correspond  with  M^hat  Rokitansky  (Pathologische  Anatomie,  i,  96)  has  dis- 
tinguished as  fibrinous  and  croupous;  the  varieties  which  he  names  croupous  a,  |8,  and  y^  re- 
presenting the  several  grades  of  lymph  in  which  the  corpuscles  gradually  predominate  more 
and  more  over  the  fibrine,  and  assume  more  of)  the  characters  of  the  pus-cell.  I  would  have 
used  his  terms,  but  that,  in  this  country,  we  have  been  in  the  habit  of  considering  croupous 
exudations  to  be  peculiarly  fibrinous. 

I  described  the  healing  of  subcutaneous  wounds  as  usually  accomplished  by  a  fibrinous 
material,  and  that  of  open  wounds  by  cells  which,  with  their  intercellular  substance,  de- 
veloped into  fibres.  These  materials  exactly  correspond  in  appearance  and  modes  of  de- 
velopment with  the  fibrinous  and  corpuscular  varieties  of  inflammatory  lymph.  And  what 
was  then  said  of  the  liability  of  the  cells  formed  in  the  repair  of  open  woundsto  be  arrested 
in  their  development  or  to  degenerate  into  pus-cells  and  lower  forms,  and  of  the  consequent 
insecurity  of  this  mode  of  repair  as  compared  with  the  subcutaneous,  is  confirmed  by  the 
corresponding  history  of  the  two  varieties  of  lymph. 

*  See  Ormerod:  Lectures  on  Valvular  Disease  of  the  Heart. — Medical  Gazette,  1851. 


LYMPH.  237 

the  blood,  so  is  the  lymph  more  fibrinous  or  corpuscular  ;  more  charac- 
teristic of  the  adhesive  or  of  the  suppurative  inflammation. 

Some  of  the  best  evidence  for  this  is  supplied  by  Rokitansky,  in  the 
first  volume  of  his  "Pathological  Anatomy;"  a  work  that  I  cannot 
again  mention  without  a  tribute  of  respect  and  admiration  for  its  au- 
thor, since  in  it,  more  than  in  any  other  of  his  writings,  he  has  proved 
himself  the  first  among  all  pathologists,  in  knowledge  at  once  profound, 
minute,  and  accurate,  in  power  of  comprehending  the  vastest  catalogue 
of  single  facts,  and  in  clear  discernment  of  their  relations  to  one  an- 
other, and  to  the  great  principles  on  which  he  founds  his  systems.  In 
this  work,  he  has  shown  clearly,  that  the  characters  of  inflammatory 
deposits,  in  difi"erent  diatheses,  correspond  very  generally  and  closely 
with  those  of  the  coagula  found  in  the  heart  and  pulmonary  vessels ; 
and  that,  in  general,  the  characters  of  inflammatory  lymph,  formed 
during  life,  are  imitated  by  those  of  clots  found  in  the  body  after  death, 
when  tke  fibrine  of  the  blood  may  coagulate  very  slowly,  and  in  contact 
with  organic  substances. 

Other  evidence  may  be  obtained  by  examining  the  products  of  simi- 
lar inflammations  excited  in  several  persons,  in  whom  the  state  of  the 
blood  may  be  considered  dissimilar.  And  here,  the  evidence  may  be 
more  pointed  than  in  the  former  case ;  for,  if  it  should  appear  that  the 
same  tissue,  inflamed  by  the  same  stimulus,  will,  in  different  persons, 
yield  difierent  forms  of  lymph,  we  shall  have  come  near  to  certainty  that 
the  character  of  the  blood  is  that  which  chiefly  determines  the  character 
of  an  inflammation. 

To  test  this  matter,  I  examined  carefully  the  materials  exuded  in 
blisters,  raised  by  cantharides  plasters,  applied  to  the  skin  in  thirty 
patients  in  St.  Bartholomew's  Hospital.  Doubtless,  among  the  results 
thus  obtained,  there  might  be  some  diversities  depending  on  the  time 
and  severity  of  the  stimulus  applied  ;  still,  it  seemed  a  fair  test  of  the 
question  in  view,  and  the  general  result  proved  it  to  be  so.  For,  although 
the  diff"erences  in  the  general  aspects  of  these  materials  were  slight,  yet 
there  were  great  differences  in  the  microscopic  characters  ;  and  these 
differences  so  far  corresponded  with  the  nature  of  the  disease,  or  of  the 
patient's  general  health,  that,  at  last,  I  could  generally  guess  accu- 
rately, from  an  examination  of  the  fluid  in  the  blister,  what  was  the 
general  character  of  the  disease  with  which  the  patient  suffered.  Thus, 
in  cases  of  purely  local  disease,  in  patients  otherwise  sound,  the  lymph 
thus  obtained  formed  an  almost  unmixed  coagulum,  in  which,  when  the 
fluid  was  pressed  out,  the  fibrine  was  firm,  elastic,  and  apparently  fila- 
mentous. In  cases  at  the  opposite  end  of  the  scale,  such  as  those  of 
advanced  phthisis,  a  minimum  of  fibrine  was  concealed  by  the  crowds  of 
corpuscles  imbedded  in  it.  Between  these  were  numerous  intermediate 
conditions  which  it  is  not  necessary  now  to  particularize.  It  may  suf- 
fice to  say  that,  after  some  practice,  one  might  form  a  fair  opinion  of 
the  degree  in  which  a  patient  was  cachectic,  and  of  the  degree  in  which 


238  PRODUCTS     OF    INFLAMMATION: 

an  inflammation  in  him  would  tend  to  the  adhesive  or  the  suppurative 
character,  hy  these  exudations.  The  highest  health  is  marked  by  an 
exudation  containing  the  most  perfect  and  unmixed  fibrine  ;  the  lowest, 
by  the  formation  of  the  most  abundant  corpuscles,  and  their  nearest 
approach,  even  in  their  early  state,  to  the  characters  of  pus-cells.  The 
degrees  of  deviation  from  general  health  are  marked,  either  by  in- 
creasing abundance  of  the  corpuscles,  their  gradual  predominance  over 
the  fibrine,  and  their  gradual  approach  to  the  characters  of  pus-cells ; 
or,  else,  by  the  gradual  deterioration  of  fibrine,  in  which,  from  being 
tough,  elastic,  clear,  uniform,  and  of  filamentous  appearance  or  filamen- 
tous structure,  it  becomes  less  and  less  filamentous,  softer,  more  paste- 
like, turbid,  nebulous,  dotted,  and  mingled  with  minute  oil-molecules. 

I  would  not  make  too  much  of  these  observations.  They  are  not 
enough  to  prove  more  than  the  rough  truth,  that  the  products  of  similar 
inflammations,  excited  in  the  same  tissue,  and  by  the  same  stimulus, 
may  be  in  different  persons  very  diff"erent,  varying  especially  in  accord- 
ance with  the  several  conditions  of  the  blood.  Yet,  simple  as  the  ob- 
servations are,  they  may  illustrate  what  often  seems  so  mysterious ; 
namely,  the  different  issues  of  severe  injuries  inflicted  on  different  per- 
sons. To  what,  more  than  to  the  previous  or  some  acquired  condition 
of  the  blood,  can  we  ascribe,  in  general,  the  various  consequences  that 
follow  the  same  operations  on  different  patients  ?  The  local  stimulus, 
and  the  conditions  by  which  the  inflammatory  product  finds  itself  sur- 
rounded, may  be  in  all  alike :  but,  as  in  the  simpler  case  of  the  blister, 
the  final  events  of  the  inflammation  are  in  accordance  with  the  state  of 
the  blood. 

I  cannot  doubt  that  a  yet  closer  correspondence  between  the  blood, 
and  the  products  of  inflammation  derived  from  it,  would  be  found  in  a 
series  of  more  complete  observations ;  in  such,  for  instance,  that  the 
characters  of  the  blood  drawn  during  life,  or,  much  better,  of  the  clots 
taken  from  the  heart  after  death,  might,  in  a  large  number  of  patients, 
be  compared  with  those  of  inflammatory  exudations  produced,  as  in  the 
cases  I  have  referred  to,  by  the  same  stimulus  applied  to  the  same 
tissues.  In  the  few  cases  in  which  I  have  been  able  to  make  such 
examinations,  this  view  has  been  established ;  and  it  is  confirmed  by 
the  parallelism  between  the  varieties  of  lymph  that  may  be  found  in 
blisters,  and  the  varieties  of  the  fibrinous  coagula  in  the  heart  described 
by  Rokitansky.*  The  varieties  of  solidified  fibrine  which  he  classes  as 
fibrines  1,  2,  3,  4,  are  very  nearly  parallel  with  what  I  have  enumerated 
as  the  stages  from  the  best  fibrinous  to  the  corpuscular  lymph ;  and, 
as  I  have  already  implied,  he  regards  these  clots  found  in  the  heart  and 
vessels  as  representing  the  different  "  fibrinous  erases"  or  diatheses  of 
the  blood. 

*  Pathologische  Anatomie,  B.  i,  p.  142. 


LYMPH.  239 

I  mentioned,  as  the  second  condition  determining  the  character  of 
inflammatory  lymph,  the  seat  or  tissue  which  the  inflammation  occupies, 

I  need  hardly  remind  you  that,  since  the  time  of  Bichat,  there  has 
been  a  general  impression  that  each  tissue  has  its  proper  mode  and 
product  of  inflammation.  The  doctrines  of  Bichat  on  this  point  were, 
indeed,  only  the  same  as  Mr.  Hunter  held  more  conditionally,  and, 
therefore,  more  truly ;  but  they  gained  undisputed  sway  among  the 
principles  of  that  pathology  which  rested  on  general  anatomy  as  its 
foundation. 

The  facts  on  which  it  is  held  that,  in  general,  each  part  or  tissue  is 
prone  to  the  production  of  one  certain  form  of  inflammatory  exudation, 
are  such  as  these :  that,  e.  g.  in  the  apparently  spontaneous  inflamma- 
tions of  the  skin,  lymph  with  corpuscles  alone  is  produced,  as  in  herpes, 
eczema,  erysipelas ;  that  in  serous  membranes,  the  lymph  is  commonly 
fibrinous,  and  has  a  great  tendency  to  be  organized,  and  form  adhe- 
sions ;  that  in  mucous  membranes  there  is  as  great  a  tendency  to  sup- 
puration ;  that  in  the  lungs,  both  fibrine  and  corpuscles  are  abundant 
in  the  lymph,  and  the  corpuscles  have  a  remarkable  tendency  to  degene- 
rate into  either  pus-cells  or  granule-cells  ;  that  in  the  brain  and  spinal 
cord  the  tendency  is  to  the  production  of  a  preponderance  of  corpuscles, 
that  quickly  degenerate  into  granule-cells,  while  in  the  areolar  tissue, 
both  fibrine  and  corpuscles  appear,  on  the  whole,  equally  apt  to  degene- 
rate into  pus,  or  to  be  developed  into  filamentous  tissue. 

Now  these  are,  doubtless,  facts ;  but  the  rules  that  it  is  sought  to 
establish  from  them  are  not  without  numerous  exceptions.  The  in- 
stances I  have  lately  quoted  show  that,  in  one  tissue  at  least,  the  skin, 
the  product  of  inflammation  will  vary  according  to  the  condition  of  the 
blood,  although  the  inflammation  be  always  similarly  excited  by  the 
same  stimulus.  So,  too  (as  Mr.  Hunter  remarks*),  if  it  were  the  tissue 
alone  that  determines  the  character  of  an  inflammation,  we  ought  to 
have  many  forms  of  inflammation  in  the  same  stump  after  amputation  ; 
whereas,  all  is  consistent,  or  the  diff"erences  among  the  tissues  are  only 
differences  of  degree ;  they  all  adhere,  or  all  granulate  and  suppurate, 
or  all  alike  inflame  and  slough. 

It  is  therefore  not  unconditionally  true  that  each  tissue  has  its  proper 
mode  and  product  of  inflammation.  It  has  been  too  much  overlooked 
that  a  morbid  condition  of  the  blood,  or  perhaps  even  of  the  nervous 
force,  may  determine,  at  once,  the  seat  of  a  local  inflammation,  and 
the  form  or  kind  of  inflammatory  product.  Thus,  e.  g.  the  variolous 
condition  of  the  blood  may  be  said  to  determine,  at  once,  an  inflamma- 
tion of  the  skin,  and  the  suppurative  form  of  inflammation ;  for,  in 
variola,  whatever  and  wherever  inflammations  arise,  they  have  a  suppu- 
rative tendency.  So,  in  rheumatism,  whether  it  be  seated  in  muscles, 
ligaments,  or  synovial  membranes,  in  serous  membranes,  or  in  fibrous 

*  Works,  vol.  iii,  p.  313. 


240  PRODUCTS     OF    INFLAMMATION: 

tissues,  there  appears  the  same  tendency  to  serous  and  fibrinous  effu- 
sions, which  are  slow  to  coagulate  or  organize,  and  even  less  prone  to 
suppuration.  The  same  might  be  said  of  the  local  inflammations  that 
are  characteristic  of  typhus  and  of  gout,  and,  I  believe,  of  all  those  dis- 
eases in  which  a  morbid  condition  of  the  blood  manifests  itself  in  some 
special  local  error  of  nutrition.  And  all  these  cases  are  illustrative  of 
the  general  truth,  that  each  morbid  condition  of  the  blood  is  prone  both 
to  produce  an  inflammation  in  a  certain  part,  and  to  give  to  that  inflam- 
mation a  certain  form  or  character. 

Cases,  however,  remain,  that  prove  some  influence  of  the  tissue  in  de- 
termining the  product  of  its  inflammation  ;  in  determining,  I  mean,  the 
primary  form,  as  well  as  the  later  development,  of  the  product :  and 
the  true  influence  of  the  tissue  in  this  respect  is  best  shown  in  some  of 
the  cases  in  which  the  inflammation,  excited,  apparently,  by  the  same 
means,  has  happened  coincidently  in  two  or  more  very  different  parts 
in  the  same  person.  Thus  we  may  find,  e.  g.  that,  in  pleuro-pneumonia, 
the  lymph  on  the  pleura  is  commonly  more  fibrinous  than  that  within 
the  substance  of  the  lung ;  and  adhesions  may  be  forming  in  the  one, 
while  the  other  is  suppurating.  In  cases  of  coincident  pneumonia  and 
pericarditis,  the  lymph  in  the  lung  may  appear  nearly  all  corpuscular, 
and  all  the  corpuscles  may  show  a  tendency  to  degenerate  into  granule- 
cells  while  the  lymph  on  the  pericardium  may  have  a  preponderance  of 
fibrine,  and  what  corpuscles  it  has  may  tend  to  degenerate  into  pus-cells. 
So,  too,  one  may  find,  in  the  substance  of  an  inflamed  synovial  mem- 
brane, abundant  lymph-cells,  while  the  exudation  on  its  surface  may 
appear  purulent. 

I  have  said  that  the  fluid  of  the  sac  in  cases  of  strangulated  hernia 
coagulates  on  withdrawal  from  the  body :  it  may  be  regarded  as  a  mix- 
ture of  serum  and  fibrinous  lymph  from  the  inflamed  serous  membrane. 
But,  in  a  case  in  which  I  was  able  to  examine  a  pellucid  fluid  contained 
in  large  quantity  in  the  cavity  of  the  strangulated  intestine,  and  which 
appeared  to  be  the  nearly  pure  product  of  inflammation  of  the  mucous 
membrane,  there  was  no  fibrine  ;  the  fluid  was  albuminous,  and  contained 
abundant  lymph-cells. 

Other  instances  of  this  might  be  mentioned.  These,  however,  may 
seem  enough  to  establish  the  influence  of  the  second  condition  that  I 
mentioned ;  namely,  the  seat  of  an  inflammation,  as  determining  the 
character  of  its  products. 

The  third  condition  on  which  the  character  of  the  lymph  chiefly  de- 
pends is,  the  degree  of  the  inflammation  producing  it. 

The  influence  of  a  tissue,  in  determining  the  character  of  the  lymph 
formed  in  its  inflammations,  may  be  in  some  measure  explained,  by  be- 
lieving that  the  primary  product  of  inflammation  is,  often,  a  mixture  of 
lymph,  and  of  the  secretion,  or  other  product,  of  the  inflamed  part, 
more  or  less  altered  by  the  circumstances  of  the  inflammation. 


LYMPH.  241 

When  it  is  seen  that  in  inflammations  of  bone  the  lymph  usually  ossi- 
fies ;  in  those  of  ligament,  is  converted  into  a  tough  ligamentous  tissue  ; 
and  that,  in  general,  lymph  is  organized  into  a  tissue  more  or  less  cor- 
responding with  that  from  whose  vessels  it  was  derived :  it  is  usually 
concluded  that  this  happens  under  what  is  called  the  assimilative  influ- 
ence of  the  tissues  adjacent  to  the  organized  lymph.  But  we  may 
better  explain  the  facts,  by  believing  that  the  material  formed  in  the 
inflammation  of  each  part  partakes,  from  the  first,  in  the  properties 
of  the  natural  products  of  that  part ;  in  properties  which,  we  know, 
often  determine  the  mode  of  formation  independently  of  any  assimila- 
tive force  (p.  61). 

We  have  some  evidence  of  this  in  the  products  of  inflammation  of 
secreting  organs,  the  only  structures  the  natural  products  of  which  we 
can  well  examine  in  their  primary  condition.  In  a  moderate  amount  of 
inflammation  of  a  secreting  gland,  the  discharge  is  usually  a  mixture 
of  the  proper  secretion  in  a  more  or  less  morbid  state,  and  of  the  in- 
flammatory product.  Thus  we  find  morbid  urine  mixed  with  fibrine,  or 
albumen,  or  pus.  In  cases  of  inflamed  mucous  membranes,  the  pro- 
duct is  often  a  substance  with  characters  intermediate  between  those  of 
the  proper  mucous  secretion  and  those  of  lymph.  Or,  again,  in  serous 
membranes,  we  may  perceive  a  relation  between  their  natural  secretion 
and  the  usual  products  of  their  inflammation. 

Now,  these  considerations  are  equally  illustrative  of  the  influence  of 
the  third  among  the  conditions  enumerated  as  determining  the  charac- 
ter and  tendency  of  inflammatory  products ;  namely,  the  degree  or 
severity  of  the  disease.  For,  as  a  general  rule,  the  less  the  degree  of 
inflammation  is,  the  more  is  the  product  like  that  naturally  formed  in 
or  by  the  part,  till  we  descend  to  the  border  at  which  inflammation 
merges  into  an  exaggerated  normal  process  of  secretion  :  as  in  hydrops 
articuli,  hydrocele,  coryza,  &c. 

These,  it  may  be  said,  are  only  instances  of  secretions.  But  the 
instances  of  the  so-called  inflammatory  hypertrophies  may  be  regarded 
as  parallel  with  those  just  referred  to  ;  for  the  analogies  between  secre- 
tion and  nutrition  are  so  numerous,  the  parallel  between  them  is  so 
close,  that  what  can  be  shown  of  one  may  be  very  confidently  assumed 
of  the  other.  We  may  therefore  believe,  that,  in  the  inflammation  of 
any  part,  the  product  will,  from  the  first,  have  a  measure  of  the  par- 
ticular properties  of  the  material  employed  in  the  normal  nutrition  of 
the  part :  that,  as  in  the  inflammation  of  a  secreting  organ,  some  of  the 
secretion  may  be  mingled  with  the  product  of  the  inflammation,  so  in 
that  of  any  other  part,  some  of  the  natural  plasma,  i.  e.,  some  of  the 
natural  material  that  would  be  eff'used  for  the  healthy  nutrition  of  the 
part  may  be  mingled  with  the  lymph.  The  measure  of  likeness  to  the 
natural  structure  acquired  by  the  inflammatory  product  in  its  develop- 
ment, will  thus  bear  an  inverse  proportion  to  the  severity  of  the  in- 


242  PRODUCTS     OF    INFLAMMATION: 

flammation  ;  because,  the  more  the  conditions  of  nutrition  deviate  from 
what  is  normal  the  more  will  the  material  effused  from  the  vessels 
deviate  from  the  normal  type.  In  severest  cases  of  inflammation  we 
may  believe  that  unmixed  lymph  is  produced,  the  conditions  of  the  due 
nutrition  of  the  part  being  wholly  changed  ;  but  when  the  inflammation 
is  not  altogether  dominant,  its  product  will  be  not  wholly  contrary  to 
the  natural  one,  and  will,  from  the  first,  tend  to  manifest  in  its  develop- 
ment some  characters  correspondent  with  those  of  the  natural  forma- 
tions in  the  part.  Thence,  onwards,  this  correspondence  will  increase  as 
the  new  tissue  is  itself  nourished ;  as  scars  improve,  so  do  false  mem- 
branes and  the  like  become  more  and  more  similar  to  natural  tissues. 

To  sum  up,  then,  what  may  be  concluded  respecting  the  conditions 
that,  in  the  first  instance,  may  determine  the  adhesive  or  suppurative 
characters  of  an  inflammatory  exudation :  they  are,  1st.  The  state  of 
the  blood — its  diathesis  or  crasis — '-the  power  of  which  is  evident  in  that 
the  same  material  may  be  exuded  in  many  inflamed  parts  in  the  same 
person ;  in  that  this  material  may  exhibit  peculiar  characters  corre- 
spondent with  those  of  the  blood  itself;  and  in  that,  in  different  persons, 
an  inflammation  excited  in  the  same  tissue,  and  by  the  same  stimulus, 
will  produce  different  forms  of  lymph,  corresponding  with  differences  of 
the  blood.  2d.  The  seat  of  the  inflammation,  and  the  tissue  or  organ 
affected ;  of  which  the  influence  is  shown  by  cases  in  which,  with  the 
same  condition  of  blood,  different  forms  of  lymph  are  produced  in 
different  parts  or  organs.  3d.  The  severity,  and  acute  or  chronic 
character,  of  the  inflammatory  process,  according  to  which  the  product 
deviates  more  or  less  from  the  character  of  the  natural  secretion  or 
blastematous  effusion  in  the  part. 

The  primitive  character  or  tendency  of  any  case  of  inflammation 
might  be  represented  as  the  resultant  of  three  forces  issuing  from  these 
conditions. 

The  last  product  of  inflammation  of  which  I  have  to  speak  is  3fucus. 

Peculiar  difficulties,  owing  to  imperfect  investigations  of  what  normal 
mucus  really  is,  beset  this  portion  of  our  subject. 

Normal  mucus,  so  far  as  it  has  been  examined,  is  a  peculiar  viscid, 
ropy,  pellucid  substance,  which,  of  its  own  composition,  has  no  corpus- 
cles or  organized  particles.  Such  mucus  is  to  be  found  in  the  nasal 
cavities  of  sheep  and  most  large  mammalia,  and  in  the  gall-bladder 
when  its  duct  has  been  totally  obstructed.  In  these  parts,  mucus  may 
be  found  without  corpuscles ;  and  probably  there  are  other  examples 
of  such  pure  and  unmixed  mucus. 

With  all  these,  however,  accidental  mixtures  commonly  occur  of 
epithelial  particles  from  the  mucous  membrane,  and  of  corpuscles  from 
the  imbedded  mucous  follicles.  And  these  particles  vary  according  to 
the  seat  of  the  membrane,  the  fluid  with  which  the  mucus  may  be  mixed, 


MUCUS.  243 

as  gastric  acid,  intestinal  alkali,  &c.,  the  time  the  mucus  may  lie  hefore 
discharge,  and  other  such  conditions.* 

The  first  effect  of  a  stimulation  within  the  normal  limits  is  to  increase 
the  secretion  of  the  proper  mucus,  making  it  also  more  liquid ;  to  in- 
crease the  quantity  of  the  epithelium  cast  off  with  the  liquid ;  and, 
often,  to  induce  the  premature  desquamation  of  the  epithelium,  so  that 
particles  of  it  imperfectly  formed  may  be  found  in  the  mucus.  Many 
of  these  immature  epithelial  particles  have  been  named  mucus-corpuscles 
or  mucus-cells. 

In  an  established  inflammation  of  a  mucous  membrane,  there  appear, 
mixed  with  mucus,  and  with  imperfect  or  degenerate  epithelium,  ma- 
terials which  closely  resemble,  if  they  are  not  identical  with,  the  lymph- 
products  of  inflammation  in  other  parts.  I  am,  indeed,  disposed  to 
think  that  we  should  not  draw  a  strong  contrast  between  the  inflamma- 
tory products  of  mucous  membranes  and  those  of  serous  membranes,  and 
other  parts,  except  in  relation  to  the  material  with  which,  in  the  several 
cases,  they  are  mixed.  For,  in  certain  inflammations  of  mucous  mem- 
branes, we  find  fibrinous  exudations,  as  in  Hunter's  experiment  of 
injecting  strong  irritants  into  the  vaginae  of  asses  ;f  they  are  found, 
also,  but  less  pure,  in  croup  and  bronchial  polypus  ;|  and  I  have  seen 
them  in  the  renal  pelvis,  ureters,  and  bladder,  in  a  case  of  calculus.  In 
other  cases,  we  find,  either  without  fibrine,  or  mixed  with  minute  soft 
flakes  of  it,  corpuscles  which  are,  also,  commonly  called  mucus-cor- 
puscles, but  which  appear  to  differ  from  those  in  the  lymph  already 
described,  only  because  of  the  peculiarly  viscid  fluid  in  which  they  lie. 
All  appear  to  be,  alike,  lymph-corpuscles ;  but  in  the  one  case  they  lie 
in  a  serous,  in  the  other  in  a  mucous  fluid,  in  which  they  appear  clearer, 
more  glistening,  more  perfectly  pellucid,  less  plump,  and  are  less  acted 
on  by  water. 

From  these  inflammatory  products  in  mucus  may  be  derived,  by 
various  degenerations  of  the  fibrine,  the  flaky  and  molecular  materials 
which  commonly  make  morbid  mucus  look  turbid  and  opaque ;  and  by 
corresponding  degenerations  of  the  corpuscles  the  more  frequent  pus- 
cells,  which  make  the  transition  to  the  complete  pus  formed  on  mucous 
membranes  in  active  inflammation. 

Such  degenerations  are  more  frequent  in  the  products  of  inflamed 
mucous  surfaces  than  are  any  forms  of  development.  Development  of 
fibrine,  I  suppose,  never  happens  here ;  but  in  the  corpuscles  some  indica- 

*  Some  observations  have  recently  been  recorded  by  Remak  and  Eberth  (Virchow's 
Archiv,  vol.  xx,  p.  198,  vol.  xxi,  p.  106),  vi^hich  appear  to  show  that  the  mucus-corpuscles 
may  form  in  the  interior  of  the  epithelium  cells  covering  the  surface  of  the  mucous  mem- 
brane. Ebertli  considers  that  the  nucleus  of  the  epithelium  cell  divides,  and  that  each  of 
the  divisions  become  invested  vfith  a  finely  granular  mass  derived  from  the  cell-contents,  so 
that  several  mucus-corpuscles  may  arise  in  a  single  epithelium  cell.  The  rupture  of  the 
wall  of  the  latter  sets  the  corpuscles  free. 

t  Works,  vol.  iii,  p.  341.     Museum  of  the  College,  Nos.  83,  84. 

J  See  Henle,  in  his  Zeitschrift,  t.  ii,  p.  178. 


244 


PRODUCTS    OF    INFLAMMATION; 


tions  of  it  may  be  found,  especially  when  tlie  inflammation  is  very  slight, 
as  in  the  end  of  a  bronchitis. 

In  this  case,  among  the  corpuscles,  many  may  be  found  enlarged, 
having  distinct  cell-walls,  and  clear,  well-defined  nuclei  with  nucleoli. 

But  among  these  there  are  usually  many  that  present  a  peculiar 
pigmental  degeneration.  In  the  gray,  smoke-colored  mucus,  commonly 
expectorated  at  the  close  of  bronchitis,  the  peculiar  color,  though  com- 
monly ascribed  to  the  mixture  of  inhaled  carbon,  is  due  to  the  abun- 
dance of  cells  containing  more  or  less  numerous  black  pigment-granules. 
Particles  of  carbon  or  soot  may  by  chance  be  present,  but  they  only 

Pig.  33. 


trivially  contribute  to  the  color ;  it  depends  on  the  number  of  these 
pigment-cells,  to  which  it  is  easy  to  trace  the  transitions  from  the 
lymph  or  mucus-corpuscles.  The  chief  stages  of  transition  are  seen  in 
that  the  cells  enlarge  to  a  diameter  of  about  jsVoth  of  an  inch,  become 
clearer,  and  acquire  one  or  two  clear  oval  nuclei ;  but,  at  the  same  time, 
minute  black  granules,  almost  like  those  of  melanotic  cells,  accumulate 
in  them ;  and  these,  increasing  in  number  and  clustering,  may  at  length 
fill  the  whole  cell,  while  the  nucleus  disappears.  Subsequently,  the  cell- 
wall  may  burst  or  dissolve,  and  the  black  granules  be  set  free. 

It  can  hardly  be  supposed  that  the  black  granules  are  in  any  way 
derived  from  inhaled  carbon,  although  it  seems  that  this  kind  of  mucus 
is  most  abundant  in  those  who  are  exposed  to  atmospheres  laden  with 
coal-smoke;  for  the  color  is  completely  destroyed  by  immersing  the 
mucus  in  nitric  acid  or  solution  of  chlorine.  The  occurrence  of  such 
pigment-cells,  being,  I  believe,  peculiar  to  the  mucus  of  the  air-passages, 
may  be  connected  with  the  general  tendency  of  inflammatory  products 
to  imitate  the  properties  of  the  natural  products  of  the  inflamed  part ; 
for  they  closely  resemble  the  black  pigment-cells  from  which  the  lungs 
and  bronchial  glands  derive  their  black  spots  and  streaks  and  other 
marks.  And  it  may  be  added,  that  their  peculiar  abundance  in  the 
slightest  forms  of  bronchitis,  compared  with  their  absence  in  acute 
cases,  aff'ords  another  example,  that  the  likeness  of  the  morbid  to  the 
natural  product  is  inversely  proportionate  to  the  severity  of  the  inflam- 
mation. 


LYMPH.  245 


LECTURE    XV. 

DEVELOPMENTS    OF    LYMPH. 

In  the  last  lecture  I  considered  part  of  the  contrast  between  the  pro- 
cesses of  nutrition  in  the  normal  and  in  the  inflammatory  state,  endea- 
voring to  illustrate  the  nature  of  the  materials  exuded  from  the  blood- 
vessels of  inflamed  parts.  The  contrast  in  this  particular  cannot,  indeed, 
be  accurately  drawn  :  for  we  have,  as  yet,  no  certain  knowledge  of  either 
the  properties  or  the  quantity  of  the  material  separated  from  the  blood, 
for  the  ordinary  nutrition  of  each  part ;  we  have  no  normal  standard 
wherewith  to  compare,  in  this  respect,  the  processes  of  disease.  It  is 
evident  that  the  exudation  in  an  inflamed  part  is  superabundant ;  but 
its  error  in  quality  can  be  proved  only  by  its  diversity  in  various  cases, 
and  by  the  differences  which  it  commonly  presents  in  the  rate  and 
method  of  its  development  or  degeneration.  It  is  of  these  processes  in 
the  exuded  lymph,  and  of  the  contrast  between  them  and  the  normal 
maintenance  of  a  part,  that  I  propose  next  to  speak. 

The  biography  of  the  lymph-product  comprises  much  of  the  most 
important  part  of  the  pathology  of  inflammation :  and  if  it  were  required 
to  point  out  what,  since  Hunter's  time,  has  contributed  most  to  the  pro- 
gress of  general  pathology,  one  could  scarcely  hesitate  to  name  the  full 
appreciation  of  the  fact,  that  inflammatory  lymph,  and  other  primary 
products  of  disease,  have  an  independent  life,  and  are  of  their  own 
nature,  capable  of  appropriate  development,  degeneration,  and  disease. 
We  may  regard  this  as  one  of  the  best  achievements  of  the  observations 
which  Schleiden  and  Schwann  began  to  generalize ;  for,  till  it  was 
clearly  apprehended,  the  idea  of  a  part  being  organizable  meant  scarcely 
more  than  that  it  admitted  of  being  organized  by  the  forces  of  the  parts 
around  it ;  that  it  could  be  built  up  by  the  arteries,  and  modelled  by 
the  absorbents,  as  a  material  plastic,  yet  passive,  in  the  hands  of  work- 
men. Hence  was  derived  the  erroneous  direction  of  inquiries,  which 
sought  for  bloodvessels  as  the  essential  characters  of  organic  life  in  a 
part ;  and  for  their  varieties  of  size,  and  number,  and  arrangement,  as 
the  measures  of  the  ability  and  method  of  development. 

Now,  more  truly,  we  may  study  the  lymph,  as  having  a  life  only  so 
dependent  on  the  blood  and  vessels  as  are  all  the  tissues  of  the  body — 
dependent  on  them  as  conditions  of  life,  but  not  as  sole  arbiters  of  the 
method  or  direction  of  the  vital  transformations.  And  I  venture  to 
think,  that  the  chief  aim  of  our  observations,  in  this  part  of  the  patho- 
logy of  inflammation,  should  be  to  learn,  now,  the  exact  relation  in 
which  the  several  products  of  inflammation  stand  to  certain  primary 
forms,  as  developments  or  degenerations  froru  them.  The  catalogue  of 
various  corpuscles  is  already  swollen  to  an  extent  that  is  confusing  to 
those  who  are  familiar  with  them,  and  repulsive  to  those  who  would 


246  DEVELOPMENT    OF    LYMPH: 

begin  to  study  them.  It  would  be  an  easy  task  to  increase  it,  and  it 
miglit  have  a  seeming  of  accuracy  to  do  so ;  but  what  we  want,  is  such 
a  history  of  the  inflammatory  lymph,  that  we  may  arrange  the  compo- 
nents of  this  catalogue  as  indicating  so  many  progressive  stages  of 
development,  degeneration,  or  disease,  in  the  primary  products  of  in- 
flammation. An  attempt  to  construct  such  a  history  is  the  more  ad- 
visable, for  the  sake  of  the  illustration  which  it  may  aff"ord  to  the  history 
of  normal  structures.  There  are,  as  I  have  already  said,  no  normal 
instances  in  which  we  can  see  the  materials  that  are  efi"used  for  the 
nutrition  of  parts ;  but  we  may  assume  something  concerning  them  and 
their  progressive  changes  from  the  analogy  of  the  materials  that  are 
more  abundantly  produced  in  inflammations. 

I  propose,  then,  to  devote  the  present  lecture  to  some  general,  and 
only  a  very  general  account  of  the  developments  of  lymph.  But  let 
me  first  state  the  sense  in  which  the  term  development  is  here  to  be 
employed. 

I  have  said  (pp.  27  and  86),  that  in  the  generally  accepted  meaning 
of  development,  we  have  adopted  an  arbitrary  standard  of  comparison, 
in  the  assumption  that  the  nearest  approach  to  organic  perfection  is  in 
the  human  body  at  the  age  of  manhood.  The  assumption  may  be  right 
on  the  whole  ;  and  a  less  arbitrary  definition  of  development  would, 
probably,  be  less  useful ;  yet  it  may  be  observed,  that  in  what  we  take 
for  the  period  and  standard  of  perfection,  many  parts  that  were  once 
highly  organized  and  active  have  passed  away,  as  the  thymus  gland ; 
and  some  are,  in  certain  respects,  rather  degenerated  than  developed, 
as  the  renal  capsules  and  the  bones.  Development,  in  its  highest  sense, 
should  imply  not  merely  that  a  part  becomes  more  fit  for  membership 
under  the  most  perfect  economy,  but  also  that  such  fitness  is  acquired 
with  greater  complexity  of  chemical  composition,  or  with  greater  evi- 
dence of  formative  or  other  organic  power,  or  with  greater  difierence 
from  the  structure  or  composition  of  lower  beings.  With  none  of  these 
characters  of  development  does  such  a  process  as  that  of  ossification 
agree ;  and,  therefore,  as  I  have  said  before,  when  we  call  it  the  de- 
velopment of  bone  from  cartilage,  it  should  be  with  the  understanding 
that  the  term  is  applicable  only  because  bone  is  the  proper  material  of 
the  skeleton  of  the  adult  human  body. 

This  distinction  is  important  in  the  pathology  of  inflammation.  In 
all  true  or  complete  development,  we  may  believe  there  is  a  larger  ex- 
penditure of  vital  force  than  in  any  other  organic  act ;  for  all  such  de- 
velopment, too,  the  external  conditions  need  to  be  the  most  complete, 
and  the  least  interfered  with ;  such  development  is  the  highest  achieve- 
ment of  the  formative  force,  the  highest  instance  of  what  might  be 
understood  as  "increased  action"  in  a  part. 

To  speak,  therefore,  of  the  development  of  inflammatory  products, 
when  already  the  normal  development  of  the  body  is  completed,  may 


NECESSARY    CONDITIONS.  247 

seem  to  imply  the  exercise  of  unusual  vital  force  ;  the  renewal,  as  it 
were,  of  the  pristine  embryonic  vigor ;  and  the  existence  of  conditions 
more  favorable  for  nutrition  than  even  those  of  health  are.  But  we 
may  be  led  to  judge  differently,  if  it  should  appear  that  most  or  all  of 
the  so-called  developments  of  inflammatory  products  are  instances  in 
which  the  tissues,  though  they  are  formed  into  the  likeness  of  such  as 
exist  in  the  perfect  human  frame,  yet  acquire  characters  of  lower  or- 
ganization than  those  they  had  in  their  earliest  state.  It  will  appear 
that  they  are  such ;  and  that  however  much  the  inflammatory  products 
may  become,  by  their  changes,  better  suited  for  the  general  purposes 
of  the  economy,  they  are,  in  relation  to  their  own  condition,  rather 
degenerated  than  developed.  The  changes  that  they  undergo  are, 
therefore,  not  always  declaratory  of  a  large  expenditure  of  vital  force  ; 
they  are  not  such  as  the  term  "sthenic,"  or  "increased  action,"  ap- 
plied to  the  inflammatory  process,  would  suggest ;  not  such  as  to  imply 
that  it  is  an  exaggeration  of  any  normal  method  of  nutrition. 

With  this  understanding,  however,  the  changes  I  shall  presently  de- 
scribe may  be  called  developments  of  inflammatory  lymph  or  exudation  ; 
they  are  developments  in  the  sense  of  being  approximations  to  the  like- 
ness of  the  natural  tissues  of  the  adult  human  body. 

In  the  last  lecture  I  spoke,  generally,  of  the  conditions  upon  which 
depends  the  production  of  such  inflammatory  lymph  as  may  be  most 
apt  for  development.  They  are  all  such  as  favor  the  production  of  a 
lymph  rich  in  fibrine,  and  that  fibrine  clear,  homogeneous,  elastic,  tough, 
and  filamentous.  But  even  such  lymph  as  this  may  altogether  fail  to 
be  developed,  or  may  be  arrested  in  any  stage  of  its  development,  and 
turned  into  the  downward  course  of  degeneration,  unless  favorable  ex- 
ternal conditions  are  present  with  it.  For  the  development  of  lymph, 
of  whatever  form,  nearly  all  those  conditions  are  requisite  which  are 
necessary  for  the  normal  development  of  the  proper  constituents  of  the 
body.  It  needs,  in  general,  the  due  supply  of  healthy  and  appropriate 
blood,  the  normal  influence  of  the  nervous  force,  and,  for  the  highest 
and  latest  forms  of  development,  the  normal  conditions  of  the  proper 
elements  of  the  affected  part. 

Now,  the  existence  of  these  conditions  for  the  de|velopment  of  lymph 
implies  a  cessation  of  the  inflammatory  process,  and  a  recovery  from 
whatever  originated  or  maintained  the  inflammation.  So  long  as  in- 
flammation lasts,  no  high  development  of  the  exudation  already  formed 
will  take  place ;  rather,  fresh  lymph  will  be  continually  exuded,  hinder- 
ing the  due  process  of  development,  and  hindering  it  the  more,  because, 
as  the  general  health  sufiers  through  the  continuance  of  the  disease,  so 
the  lymph  freshly  formed  will  be  less  and  less  prone  to  organization. 
We  may  see  this  illustrated  in  bad  cases  of  pleurisy.  The  layers  of 
lymph  next  to  the  pleura  are  always  more  prone  to  organization  than 
the  later-formed  layers  that  lie  next  the  cavity ;  while  within  the 
cavity  all  the  lymph  may  retain  its  fluid  form,  or  may  have  degenerated 


248  DEVELOPMENT    OP    LYMPH: 

into  pus.  So,  more  openly,  we  may  see  an  illustration  of  the  ill  effects 
of  abiding  inflammation,  in  the  healing  of  wounds  by  granulation.  An 
inflammation,  ensuing  or  continuing  in  the  wound,  hinders  all  develop- 
ment of  granulation-cells,  even  though  it  may  be  too  slight  to  hinder 
their  formation,  and  may  be  favorable  to  the  production  of  the  ichor- 
and  pus-cells.  We  may  truly  say,  that  the  conditions  most  favorable 
to  the  abundant  production  of  lymph  are  among  the  most  unfavorable 
to  its  development,  i.  e.,  to  its  complete  and  higher  organization. 

Even  when  the  inflammation  has  ceased,  and  fresh  lymph  is  not 
formed,  still,  development  is  often  prevented  or  retarded  for  want  of 
some  necessary  condition.  The  bloodvessels,  long  dilated,  may  remain 
in  a  state  of  congestion,  distended  as  if  paralyzed,  and  filled  with  slowly 
movino-  blood.  In  such  a  state  of  "passive  congestion,"  so  apt  to 
follow  more  acute  attacks,  development  will  not  happen  in  even  well- 
disposed  lymph.  We  have  parallel  facts  in  the  tardy  development  of 
granulations  on  the  legs,  in  the  healing  of  ulcers ;  and  how  much  this 
depends  on  the  defective  moveuaent  of  the  blood  is  well  illustrated  by  a 
specimen*  appropriate  to  an  observation  of  Mr.  Hunter's.  It  shows 
three  ulcers  of  the  integuments  of  a  leg ;  they  were  all  granulating, 
and  all  healing ;  but  their  progress  in  healing  was  inversely  propor- 
tionate to  the  hinderances  of  the  blood.  The  lowest  of  the  three,  that 
most  distant  from  the  heart,  and  of  which  the  vessels  were  subject  to 
the  pressure  of  the  highest  column  of  blood,  was  least  advanced  in 
healing ;  while  the  uppermost  of  the  three  was  most  advanced,  and  was 
nearly  cicatrized. 

But  let  us  suppose  all  the  conditions  for  development  provided ;  what 
will  now  determine  the  direction  or  result  of  the  process  ?  Into  what 
tissues  will  the  lymph  be  formed  ?  Two  chief  things  will  determine 
this :  first,  the  general  natural  tendency  of  organizable  lymph,  pro- 
duced in  inflammation,  is  to  form  filamentous,  i.  e.  fibro-cellular,  con- 
nective or  fibrous  tissue ;  and,  secondly,  all  lymph  has  some  tendency 
to  assume,  sooner  or  later,  the  characters  of  the  tissues  in  or  near 
which  it  is  seated,  or  in  place  of  which  it  is  formed. 

The  natural  tendency  of  lymph  to  the  construction  of  fibro-cellular 
or  connective  tissue,  such  as  composes  false  membranes  or  adhesions, 
and  many  permanent  thickenings  and  indurations  of  parts,  is  shown  by 
the  production  of  this  tissue  under  all  varieties  of  circumstances,  and 
in  nearly  all  parts ;  even  in  parts  which,  naturally,  contain  little  or 
none.  Thus,  it  is  found  in  the  brain,  and  in  glands,  as  in  the  testicle : 
within  joints,  even  where  adhesions  only  pass  from  one  articular  car- 
tilage to  another  ;  in  the  adhesions  and  thickenings  of  the  most  diverse 
serous  membranes ;  in  the  thickenings  of  the  most  diverse  mucous  ones. 
And  with  all  these,  we  have  the  corresponding  facts  in  the  healing  of 
wounds.     All  granulations,  springing  from  what   surface   they  may, 

*  Museum  of  the  College,  No.  26. 


NECESSARY    CONDITIONS.  249 

tend,  at  least  in  the  first  instance,  to  the  formation  of  filamentous 
tissue,  such  as  we  see  uniting  all  parts  in  a  stump  ;  and  a  large  pro- 
portion of  subcutaneous  injuries  are  repaired  by  similar  tissue,  what- 
ever parts  may  have  been  divided.  And,  sometimes,  we  may  find 
incomplete  instances  of  this  development  where  the  lymph  is  not  even 
in  continuity  with  any  tissue,  but  floats  free ;  as  in  ascites,  or  in 
efiusions  into  joints. 

But  besides  this  general  tendency,  we  may  recognize  in  inflammatory 
lymph  a  disposition  to  assume  characters  belonging  to  the  part  in  which 
it  was  produced  ;  so  that,  for  instance,  that  about  fibrous  and  ligament- 
ous parts  will  be  developed  into  peculiarly  tough  fibrous  tissue ;  that 
about  bone  will  become  osseous  ;  that  in  the  neighborhood  of  epithelium 
will  form  for  itself  an  epithelial  covering  ;  and  so  on.  I  referred  to  this 
fact  in  the  last  lecture,  and  suggested  that  this  tendency  of  the  de- 
veloped lymph,  to  conform  to  the  characters  of  the  parts  around  it,  is 
probably  due  to  the  original  and  inherent  quality  of  the  lymph;  that 
the  material  formed  in  the  inflammation  of  each  part  partakes,  from  the 
first,  in  th^  properties  of  the  natural  products  of  that  part,  and  partakes 
of  them  in  an  inverse  proportion  to  the  severity  of  the  inflammation ; 
because,  the  more  the  normal  conditions  of  nutrition  are  deviated  from, 
the  more  will  the  material  produced  be  unlike  the  normal  product. 
Besides,  when  the  conditions  are  restored  to  the  normal  type,  the  or- 
ganized product  of  inflammation  will  constantly  approximate  more  and 
more  to  the  characters  of  the  parts  among  which  it  is  placed,  or  with 
which  it  has  acquired  membership.  As  scars  improve,  i.  e.  gain,  gradu- 
ally, more  of  the  characters  of  skin,  so  do  false  membranes,  and  the 
like  structures,  formed  by  the  organization  of  inflammatory  lymph,  ac- 
quire, by  their  own  nutrition  and  development,  more  nearly  the  charac- 
ters of  the  parts  with  which  they  are  connected.  Thus,  false  membranes 
in  the  serous  cavities  acquire  a  covering  of  epithelium  exactly  like  that 
which  covers  the  original  serous  membrane,  and  their  structure  is  that 
of  connective  tissue ;  adhesions  of  the  iris  may  become  black,  apparently 
from  the  production  of  pigment-cells  like  those  of  the  uvea ;  thus,  too, 
in  adhesions  of  the  pleura,  even  when  they  are  long  and  membranous, 
pigment  may  be  formed  as  in  the  pulmonary  pleura  itself ;  and  thus 
many  other  inflammatory  products  are  gradually  perfected,  till  we  may 
come  to  doubt  whether  they  be  of  normal  or  of  morbid  origin,  so  com- 
plete is  the  return  from  the  aberrant  action. 

I  will  endeavor,  now,  to  describe  more  particularly  the  transitions  to 
the  several  tissues  that  may  be  formed  from  inflammatory  lymph.  I 
need  not,  indeed,  describe  the  minute  changes  of  development ;  for,  as 
the  fibrinous  and  corpuscular  varieties  of  lymph  resemble  very  nearly 
the  two  forms  of  reparative  material,  so  (as  far  as  they  are  yet  studied), 
their  respective  methods  of  development  are  equally  similar.  On 
these  points,  therefore,  I  may  refer  to  former  lectures  (pp.  139,  e.  s., 
156,  178,  &c.) ;  and,  if  it  seem  strange  that  disease  should  thus  so 

17 


250  DEVELOPMENT     OF    LYMPH    INTO 

closely  imitate  health,  let  it  be  repeated,  that  this  process  of  develop- 
ment of  the  lymph  is  not  disease.  The  lymph  is,  indeed,  produced  in 
inflammation,  but  it  is  developed  in  health,  when  all  the  natural  condi- 
tions of  nutrition  are  restored. 

The  instances  are  very  numerous  in  which  the  inflammatory  lymph, 
following  its  natural  tendency,  becomes  connective  tissue.  The  general 
forms  which,  in  these  instances,  it  assumes  are  (1)  adhesions,  where  the 
new-formed  tissues  is  between  free  surfaces,  and  unites  them ;  (2)  thick- 
enings, where  the  formation  is  in  the  substance  of  membranes ;  (3)  in- 
durations, with,  or  without,  contractions,  where  it  is  in  the  substance  of 
organs  ;  (4)  opacities  of  certain  parts  that  were  transparent. 

The  best  examples  of  the  formation  of  connective  tissue  from  inflam- 
matory lymph  are  in  the  adhesions,  or  false  membranes,  found  after  in- 
flammation of  serous  or  synovial  membranes.  In  the  former,  especially, 
the  lymph  is  apt,  in  such  favorable  conditions  as  I  have  specified,  to  be 
thus  developed.  In  an  acute  peritonitis,  or  pleuritis,  for  instance,  it  is 
usually,  in  the  first  instance,  deposited  in  layers  of  uncertaifi  thickness 
on  the  opposed  surfaces  of  the  membrane.  The  condition  of  these 
layers  is  variable.  The  lymph  is  sometimes  grayish,  half  translucent, 
compact,  and  laminated,  consisting  chiefly  of  fibrinous  material,  and 
peculiai-ly  apt  for  development :  in  other  cases,  it  is  yellowish,  opaque, 
soft,  succulent,  or  almost  creamy,  having  a  great  preponderance  of  cor- 
puscles, and  being  less  fit  for  development :  and  between  these  forms 
are  many  connecting  varieties  of  appearance. 

In  the  first  instance,  the  connection  of  the  lymph  with  the  surface  of 
the  serous  membrane  is,  usually,  such  that  it  may  be  cleanly  stripped 
ofi".  Its  free  surface  presents  great  varieties  ;  it  may  be  flocculent,  or 
villous,  reticular,  perforated,  or  nearly  smooth.  Commonly,  at  first, 
the  surfaces  of  the  two  layers  (the  visceral  and  parietal  layers  as  they 
may  be  called,  after  the  portions  of  the  serous  membrane  on  which  they 
are  severally  placed)  are  separated  by  serous  fluid,  exuded,  in  various 
quantity,  with  the  lymph.  But  they  may  be,  in  parts,  continuous,  or 
connected  by  bands  or  columns  ;  and,  usually,  when  the  inflammation 
ceases,  and  such  a  state  of  circulation  is  restored  as  is  favorable  to  the 
organization  of  the  lymph,  the  same  state  is  equally  adapted  to  the  ab- 
sorption of  the  superabundant  fluid.  In  this  case,  the  opposed  surfaces 
of  the  two  layers  of  lymph  are  gradually  brought  into  contact  with 
one  another,  and  with  portions  of  lymph  which  had  floated  in  the  fluid  : 
and  now,  as  their  organization  proceeds,  they  are  all  united  ;  they  be- 
come continuous,  and  form  "adhesions"  between  the  opposite  surfaces 
of  the  serous  membrane,  whether  these  be  the  surfaces  of  adjacent  organs, 
as  the  abdominal  viscera,  or  of  any  organ  and  of  the  cavity  inclosing  it, 
as  in  the  case  of  the  testicle  and  tunica  vaginalis. 

The  method,  and  the  chief  part  of  the  plan,  of  the  organization  of 
lymph  in  these  cases,  are,  I  believe,  similar  to  those  described  in  the 


CONNECTIVE    TISSUE.  251 

healing  of  wounds  by  primar}^  or  by  secondary  adhesion ;  and  the  gene- 
ral results  are  the  same.  Various  as  are  the  forms  and  other  conditions 
of  adhesions  and  false  membranes  (depending  as  they  do  on  the  relative 
positions  and  mobilities  of  the  parts  that  they  connect),  yet  their  struc- 
ture, when  complete,  is,  I  believe,  uniform.  They  consist  of  well-or- 
ganized connective  tissue,  with  which  (perhaps  only  at  a  late  period) 
the  elastic  form  of  this  tissue  may  be  mingled:  they  possess  abundant 
bloodvessels,  the  chief  of  which  are  parallel  to  the  direction  of  their 
filaments;  and  their  free  surfaces  are  covered  with  an  epithelium  like 
that  of  the  membranes  which  they  connect. 

Connective  tissue  is  formed  in  adhesions  of  synovial  membranes  as 
well  as  of  serous  membranes  ;  and,  probably,  in  the  same  manner.  In 
both  cases,  moreover,  it  is  very  usual  for  lymph  to  be  exuded  in  and 
just  beneath  the  membrane,  as  well  as  on  its  surface;  and  this  infiltrated 
or  interstitial  lymph,  becoming  organized,  produces  thickening  and  opa- 
city of  the  membrane.  The  coincident  organization  of  the  lymph,  in 
both  positions,  is  well  shown  in  the  frequent  instances  of  white  spots  in 
the  cardiac  pericardium,  with  adhesions  between  the  pericardial  surfaces. 
Such  white  spots,  when  completely  formed,  consist  of  new  connective 
tissue,  exactly  like  that  of  the  adhesions.  It  is  by  similar  interstitial 
exudation  of  lymph,  and  by  its  development  into  this  kind  of  tissue, 
that  the  frequent  adhesions  take  place  between  parts  which,  though 
connected,  should  slide  freely  upon  one  another  ;  such  as  adjacent 
tendons,  &c.  From  this  is  derived  a  large  share  of  the  stiff'ness  that 
remains  about  injured  joints ;  the  parts  that  should  slide  pliantly  over 
them  are  fixed  by  the  ncAv-formed  interstitial  connective  tissue.  So, 
too,  are  formed  the  various  morbid  thickenings  of  parts  ;  as  of  pieces 
of  integument,  capsules  of  joints,  &c.  But  in  many  of  these  cases  the 
lymph  retains  very  long  its  rudimental  structures,  and  is,  perhaps,  on 
this  account,  peculiarly  apt  to  degenerate  and  permit  absorption  or  the 
ulcerative  process.  I  know  no  better  example,  for  microscopic  exami- 
nation of  interstitially  deposited  lymph,  than  an  indurated  chancre: 
but  I  have  never  found  one  in  which  the  lymph-cells  had  reached  a 
further  development  than  the  elongated  caudate  form.  When  the  exu- 
dation is  interstitial  in  any  of  the  more  compact  forms  of  connective 
tissue,  as  in  ligaments,  capsules  of  joints,  and  the  like,  the  lymph  is 
developed  into  the  denser  kinds  of  connective  tissue.  The  best  exam- 
ples of  it  are  in  the  laminated  and  nodular  thickenings  of  the  capsule 
of  the  spleen,  or  the  thickening  and  induration  of  the  periosteum,  or 
the  capsule  of  the  hip-joint  in  chronic  rheumatic  arthritis.  In  all  these 
cases,  the  new  material  is  derived  from  repeated,  but  not  acute  inflam- 
mations ;  therefore,  probably,  though  excessive,  it  is  not  widely  different 
from  the  normal  material  for  nutrition ;  and,  the  conditions  for  nutrition 
being  little  disturbed,  it  is  developed  into  the  exact  likeness  of  the  ori- 
ginal texture,  with  which  it  is  intermingled  and  confused. 

As  the  connective  tissue  formed  from  inflammatory  lymph  becomes 


252  DEVELOPMENT     OF    LYMPH    INTO 

more  perfectly  organized,  it  is  prone  to  contract:  imitating  the  con- 
traction already  described  in  granulations  and  scars  (p.  173).  Hence, 
in  part,  the  contraction  of  the  wall  of  the  chest  after  pleurisy,  and  the 
various  displacements  and  deformities  of  organs  that  have  become  ad- 
herent to  adjacent  parts :  hence,  in  part  also,  the  contractions  of 
inflamed  organs,  as  of  the  liver  in  cirrhosis :  hence,  too,  an  addition  to 
the  rigidity  of  joints  when  the  parts  around  them  have  been  inflamed ; 
and  hence,  with  yet  greater  mischief,  the  contractions  of  the  thickened 
valves,  and  tendinous  cords  of  the  heart. 

The  elastic  form  of  connective  tissue  is  sometimes  abundantly  pro- 
duced in  the  adhesions  developed  from  inflammatory  lymph.  I  have 
not  seen  it  except  in  such  as  are  completely  organized;  and  I  think  it 
is,  in  this  case,  as  in  the  formation  of  scars,  a  late  production  (see  p. 
174).  I  believe,  also,  with  Virchow,*  that  its  formation  depends,  in 
some  measure,  on  the  membrane  that  is  inflamed;  pleural  adhesions 
being  most  favorable  to  it.  In  these  it  is  often  abundant ;  its  principal, 
but  always  slender,  filaments  lying  in  the  same  general  direction  as 
those  of  the  white  fibrous  tissue. 

Adipose  Tissue  may  be  formed,  if  not  directly  from  inflammatory 
lymph,  yet  in  the  connective  tissue  of  completely  organized  adhesions. 
I  think  it  is  not  often  so :  but,  lately.  Dr.  Kirkes  found  a  lung  of  which 
all  the  anterior  part  was  covered  with  well-organized  false  membrane ; 
and  in  part  of  this  was  a  quantity  of  perfect  adipose  tissue,  more  than 
four  ounces  in  weight. 

Epithelium  I  have  already  mentioned  as  covering  the  surfaces  of 
well-formed  adhesions.  It  is  not  rare  to  find,  in  inflammation  of  serous 
membranes,  recent  lymph-cells  presenting  many  characters  indicative 
of  development  towards  epithelium ;  flattened  and  enlarged,  and  having 
circular  or  oval  clear  nuclei :  and  it  may  be  developed  in  the  form  of 
epidermis  on  the  surface  of  granulating  sores. 

Bone  is  often  formed  from  inflammatory  lymph.  It  may  appear  as 
a  late  transformation  of  lymph  that  has  been  organized  into  perfect 
fibrous  tissue ;  as  in  the  osseous  plates  that  are  sometimes  found  in  the 
false  membranes  of  the  pleura,  or  in  the  pericardium.  In  most  of  these, 
however,  there  is  not  true  bone,  but  an  amorphous  deposit  of  earthy 
matter,  which  is  imbedded  in  the  fibrous  tissue,  or  which  (as  Rokitansky 
holds)  is  the  residue  of  the  degenerated  and  partially  absorbed  tissue. 

The  proper  condition  for  the  transformation  of  lymph  into  bone  is 
that  in  which  the  exudation  takes  place  in  an  inflammation  seated  in 
the  bone  itself,  or  else,  in  or  near  the  periosteum.      Such  inflammations 

*  Verhandl.  der  Phys.-Med.  Gesselschaft  in  Wurzburg,  1850,  p.  142.  He  describes  here 
a  peculiar  thorny  or  dentate  structure  often  presented  by  the  elastic  filaments  in  old 
adhesions. 


BONE.  253 

have  been  called  "  ossific  ;"  and  the  Museum  of  the  College,  like  every 
other,  abounds  with  specimens  of  their  various  results. 

There  is  a  great  lack  of  minute  observations  respecting  both  the 
characters  of  the  lymph  exuded  in  inflammations  of  bone  or  perios- 
teum, and  the  methods  of  its  ossification.  Such  as  have  been  made, 
indicate,  as  might  be  expected,  a  close  resemblance  to  the  processes 
described  in  the  repair  of  fractures*  (p.  177,  et  seq.).  The  lymph  pro- 
duced in  moderate  inflammation,  and  therefore  likely  to  ossify,  is,  at 
first,  according  to  Rokitansky,  a  dark  red  exudation,  like  gelatine, 
which,  being  gradually  decolorized,-  becomes  white,  and  at  the  same 
time  acquiring  firmness,  becomes  like  soft  flexible  cartilage,  and  then 
like  ruddy  succulent  bone.  But  though  it  be  like  cartilage,  I  suspect 
that  cartilage  is  very  rarely,  if  ever,  formed  in  inflammation  of  bone  ; 
for  it  seems  to  be  formed  in  the  repair  of  fractures  only  when  the  con- 
ditions are  more  favorable  than  they  are  likely  to  be  in  any  inflamma- 
tions. Probably  the  lymph  is  more  or  less  developed  towards  the  fibrous 
tissue  when  it  ossifies ;  and,  as  in  the  repair  of  fractures,  so  here,  we 
may  believe  that  ossification  may  be  postponed  till  the  fibrous  tissue  is 
quite  formed,  or  that  it  may  ensue  in  the  rudimental  state  of  the  tissue, 
whether  in  a  nucleated  blastema,  or  in  cells  like  those  of  granulations. 

It  would  be  hardly  possible  to  explain,  without  illustrative  specimens, 
air  the  various  appearances  of  bone  new-formed  in  or  after  inflamma- 
tions. It  may  be  produced  in  the  very  substance  of  compact  bone,  after 
the  softening  and  expansion  of  the  original  tissue  which  occur  in  the 
earlier  parts  of  the  inflammatory  process,  and  to  which  I  shall  have 
again  to  refer.  Or,  it  may  be  produced  in  the  medullary  or  cancellous 
tissue  ;  and  here,  commonly,  it  appears  as  a  gradual  thickening  of  the 
minute  cancellous  lamellae  and  fibres  of  bone,  which,  as  they  increase, 
gradually  exclude  the  proper  structures  of  the  diploe  or  medulla,  and 
finally  coalesce  into  hard  solid  bone. 

But,  by  far  the  most  common  seat  of  the  formation  of  new  bone,  and 
that  in  which  it  is  almost  always  found  when  it  exists  in  either  of  the 
former  situations,  is  on  the  surface,  between  bone  and  periosteum,  or 
even  in  the  periosteum  itself.  Here  it  forms  the  various  growths  to 
which  the  general  term  Osteophyte  has  been  given.  In  a  series  of  speci- 
mens of  common  inflammation  of  bone  or  periosteum,  it  is  not  difficult 
to  trace  the  changes  of  construction  of  the  new  bone,  by  which,  like 
that  formed  in  a  process  of  repair,  it  gradually  approximates  to  con- 
formity with  the  bone  on  which  it  grows. f 

At  first,  it  is,  when  dried,  light  and  friable,  with  a  close  filamentous, 

*  Kostlin,  Miiller's  Archiv,  1845,  p.  60;  Rokitansky,  ii,  p.  172  ;  Virchow,  in  his  Archiv, 
i,  p.  135. 

f  Any  large  Museum  will  supply  such  specimens.  Those  in  the  College  of  Surgeons 
are  minutely  described  in  the  Catalogue,  vol.  ii,  p.  S3,  e.  s.,  and  vol.  v,  p.  43,  e.  s. ;  those  at 
St.  Bartholomew's  may  be  studied  through  the  Indices,  p.  1  and  57.  Even  different  parts 
of  a  single  specimen  will  show  much  of  what  is  described. 


254  DEVELOPMENT     OF    LYMPH: 

velvety  texture,  and  a  smooth  surface,  gradually  rising  from  that  of 
the  surrounding  healthy  bone.  As  it  increases  in  thickness  it  becomes 
longitudinally  grooved,  as  if  lodging  bloodvessels,  passing,  through  it, 
from  the  periosteum  to  the  old  bone.  Then,  as  fresh  formations  of  new 
bone  take  place,  they  assume  the  form  of  nodules  and  thick  plates,  laid 
over  the  longitudinal  grooves,  and  leaving  large  apertures  for  the  pas- 
sage of  bloodvessels.  Such  plates,  like  nearly  all  bone  new-formed  in 
disease,  present,  at  first,  a  porous  surface  and  a  finely  cancellous  lung- 
like texture.  But,  gradually,  in  whatever  form,  the  new  bone  tends  to 
become  harder  and  heavier ;  the  apertures  that  made  its  surface  porous 
D-radually  diminish  till  they  are  obliterated,  and  thus  the  new  bone, 
while  still  cancellous  within,  acquires  a  compact  external  layer,  and 
becomes  more  firmly  united  to  the  bone  beneath  it.  The  process  of  in- 
duration continuing,  the  new  bone  a^cquires  throughout  a  hard  compact 
texture :  its  outer  surface,  no  longer  porous,  becomes  nearly  as  smooth 
as  that  of  the  old  bone  ;  its  color  also  changes  to  that  of  the  old  bone  ; 
and,  finally,  the  two  unite  so  closely  that  the  boundary  line  between 
them  can  hardly  be  discerned. 

Such  is  the  gradual  assimilation  of  the  inflammatory  product  to  the 
characters  of  the  normal  structure  from  whose  disease  it  issued :  a  pro- 
cess peculiarly  worth  studying  in  the  bones,  because  in  them,  more  than 
in  any  other  tissue,  the  changes  can  be  leisurely  examined.  Those  which 
I  have  described  occur  in  common  inflammations :  such,  e.  g.,  as  follow 
injuries,  or  exist  in  the  neighborhood  of  necrosis,  or  ulceration,  or  foreign 
bodies.  They  are  generally  observed,  also,  in  specific  inflammations  of 
bone  ;  but,  among  these  it  is  worth  observing  how  characteristic  of  differ- 
ent diseases  are  certain  formations  of  the  new  bone.  The  pustules  of 
variola,  or  the  vesicles  of  herpes,  are  scarcely  more  characteristic  of 
those  diseases,  than  are  the  hard  nodules  of  cancellous  bone,  clustered 
about  the  articular  borders  of  bones  that  have  been  the  seat  of  chronic 
rheumatism ;  or  the  porous,  friable,  dirty,  and  readily  ulcerating  thin 
layers  formed  on  the  shafts  in  syphilis.* 

Cartilage,  I  have  said,  is  probably  not  formed  in  inflammatory  lymph 
in  the  process  of  its  ossification.  Neither  does  it  appear  to  be  formed 
in  the  more  acute  infiammations  of  articular  cartilage  :  but,  we  must 
not  exclude  it  from  the  possible  developments  of  inflammatory  products, 
while  we  remember  the  observations  of  Mr.  W.  Adamsf  respecting  the 
enlargements  of  the  ends  of  bones  in  chronic  rheumatic  arthritis.  In 
these,  which  are  marked  by  such  formations  of  new  bone,  and  such 
thickenings  of  fibrous  tissue,  as  we  constantly  ascribe  to  inflammations, 
there  is  manifest  increase  of  the  artic*ular  cartilage,  and  a  subsequent 
ossification  both  of  that  which  is  new  formed,  and,  more  slowly,  of  that 

*  As  in  Nos.  572,  628,  and  others,  in  the  College  Museum, 
f  Trans,  of  Pathol.  Soc.  of  London,  vol.  iii,  1S51. 


BLOOD    AND    BLOODVESSELS.  255 

which  normally  covered  the  head  of  the  bone.  The  early  conditions  of 
the  increase  of  the  cartilage  are  not  traced  :  but  that  it  depends  on  in- 
flammation, rather  than  on  true  hypertrophy,  is  probable,  both  from  the 
concurrent  signs  and  results  of  inflammation,  and  from  the  new  carti- 
lage falling  short  of  the  perfect  characters  of  the  old;  for  it  has  a 
fibrillated  intercellular  substance,  and  scattered  nuclei,  and  is  prone  to 
ossification. 

It  remains  that  I  should  describe  the  adjunct  structures  of  organized 
inflammatory  lymph.  But  this  may  be  briefly  done,  because  the  account 
of  the  formation  of  new  bloodvessels  in  granulations  and  other  repara- 
tive materials  might,  I  believe,  be  transferred  hither  (from  p.  159). 
The  question  is,  indeed,  often  raised,  as  in  the  corresponding  instance 
of  granulations  becoming  vascular,  whether  the  bloodvessels  are  formed 
entirely  of  the  material  of  the  lymph,  and,  as  it  were,  by  its  own  power 
of  development,  or  whether  they  are  outgrowths  from  adjacent  natural 
or  original  vessels,  which,  as  the  expression  is,  shoot  out  into  the  lymph. 

I  think  it  nearly  certain,  for  the  following  reasons,  that  the  lymph 
forms  neither  vessels  nor  bloody  but  receives  those  that  are  projected 
into  it  from  the  parts  on  or  in  which  it  is  placed, 

1.  The  direct  observations  supposed  to  prove  that  blood  is  formed  in 
inflammatory  lymph  are  very  liable  to  fallacy,  through  the  facility  with 
which  blood  may  be  accidentally  mixed  with  the  lymph,  in  consequence 
of  hemorrhage  during  life  or  after  death,  or  in  the  preparation  of  the 
specimens.  Where  these  sources  of  fallacy  have  been  avoided,  I  have 
never  seen  anything  suggestive  of  a  transformation  of  lymph  into  blood. 

2.  The  development  of  blood  from  tissue-cells  is  limited,  naturally, 
to  the  earliest  period  of  embryo-life,  as  if  it  needed  the  greatest  amount 
offeree  for  development ;  afterwards,  blood  is  not  formed  except  through 
a  long  process  of  elaboration,  and  with  the  aid  of  many  organs.  Its 
formation,  therefore,  in  the  mal-conditions  of  inflammation,  is  very  im- 
probable.* 

3.  In  no  specimen  of  inflammatory  lymph  have  I  seen  appearances  of 
transitions  from  lymph-cells  to  blood-cells,  such  as  we  may  see  in  the 
lymph  of  lymphatics,  both  before  and  after  it  is  poured  into  the  blood- 
vessels. 

4.  Neither  in  any  lymph  have  I  seen  appearances  of  such  stellate 
cells  as  the  interstitial  bloodvessels  of  the  early  embryo  are  formed  from  ; 
nothing  comparable  with  them  has  ever  come  into  view. 

5.  In  the  formation  of  vessels  for  granulations  and  the  walls  of 
chronic   abscesses,    all  is   favorable  to   the   belief  that  they  grow  up 

*  It  should  be  stated,  however,  that  Billroth,  in  his  researches  into  the  mode  of  formation 
of  bloodvessels  in  granulations,  has  described  and  figured  appearances  which  have  led  him 
to  suppose  that  here,  as  in  the  origin  of  the  first  blood-corpuscles  in  the  embryo,  the  contents 
of  some  of  the  granulation-cells  may  form  new  blood-corpuscles,  whilst  the  cell-membranes 
may  assist  in  the  formation  of  the  walls  of  the  new  bloodvessels. 


256 


DEVELOPMENT     OF    LYMPH    INTO 


from  the  bloodvessels  of  the  adjacent  parts ;  and  there  are  no  struc- 
tures to  which  the  lymph  bears  so  close  analogy  as  it  does  to  these,  or 
to  which  it  is  so  likely  to  be  conformed  in  the  production  of  its  vessels. 
On  the  whole,  therefore,  although  direct  observations  are  wanting,  I 
think  we  may  conclude  that  all  the  vessels  of  inflammatory  lymph  are 
formed  by  outgrowth  from  adjacent  vessels,  as  in  the  process  of  repair, 
and  that  through  these  vessels,  not  by  its  own  development,  it  derives 
its  supply  of  blood. 

In  the  first  instance,  the  bloodvessels  of  lymph  appear  to  be  usually 
very  numerous  and  thin-walled ;  therefore  easily  bursting,  or  dilated 
by  congestions  during  life,  or  in  the  attempt  to  inject  them  after  death. 
The  College  collection  contains  an  extremely  beautiful  specimen  of  soft 

recent  lymph  from  the  pericardium 
^^'     '  of  a  Cheetah,  the  vessels  of  which, 

injected  by  Mr.  Quekett,  appear 
as  numerous  and  close-set  as  those 
of  some  of  the  more  vascular  mu- 
cous membranes.  They  present 
occasional  slight  and  gradual  di- 
latations, especially  when  they 
branch  or  anastomose. 

But  after  an  uncertain  time,  as 
the  lymph  becomes  more  highly 
organized,  so  its  vessels  waste  and 
diminish  in  number;  and  while  it 
acquires  the  proper  structure  of 
the  connective  tissue,  so  it  descends 
to  the  low  degree  of  vascularity  of 
that  tissue.  The  vessels  of  false 
membranes,  as  represented  here 
(Fig.  34),  from  an  instance  in  which  they  were  naturally  injected  with 
blood,  are  usually  rather  wide  apart,  long,  slender,  and  cylindriform. 
In  all  these  particulars  they  differ  from  those  of  more  recently  vascu- 
larized lymph ;  and  their  changes  are,  in  these  respects,  parallel  with 
those  of  the  vessels  of  granulations  during  the  gradual  formation  and 
perfecting  of  scars. 

Perhaps  the  most  perfect  instance  of  the  conformity  with  the  natural 
tissues  of  the  body  to  which  the  developed  lymph  can  attain,  is  mani- 
fested in  its  acquiring  a  supply  of  lymphatic  vessels.  We  owe  the 
knowledge  of  the  lymphatics  of  false  membranes  to  the  masterly  skill 
of  Professor  Schroeder  van  der  Kolk,  whose  preparations  of  them  are 
described  and  represented  by  his  pupil,  Dr.  de  Lespinasse.*    In  Fig.  35, 

*  Spec.  Anat.  Path,  de  Vasis  novis  Pseudo-membranarum,  8vo.  Daventrise,  1842,  figs, 
iii,  iv  In  another  instance  he  injected  lymphatics  in  an  adhesion  between  the  liver  and 
diaphragm.  A  similar  injection  of  these  in  adhesions  between  an  ovarian  tumor  and  the 
small  intestines  is  described  by  Lebert:  Trait6  des  Maladies  Cancereuses,  p.  40. 


LYMPHATICS. 


257 


copied  from  one  of  his  plates,  beautiful  networks  of  lymphatics,  with 
their     characteristic     beaded 

forms   and   abundant   anasto-  ^^'  " ' 

moses,  are  shown  traversing 
adhesions  extending  between 
two  lobes  of  a  lung  ;  while  yet 
closer  networks  are  seated  in 
the  thickened  and  opaque- 
white  substance  of  the  pleura, 
or  of  false  membrane  covering 
it,  beneath  the  adhesions. 

It  seems  to  be  in  only  the 
most  perfect  state,  and  when 
bloodvessels  have  long  exist- 
ed, that  lymphatics  are  formed 
in  false  membranes.    In  recent 

lymph  Schroeder  v.  d.  Kolk  has  never  succeeded  in  injecting  any ;  and 
we  can  only  suppose  that  they  are,  like  the  bloodvessels,  produced  by 
outgrowth  from  the  lymphatics  of  the  membrane  with  which  they  are 
connected. 

Virchow*  has  twice  seen  nerve-fibres  in  adhesions.  In  one  case,  two 
fine  nerve-fibres  passed  through  an  adhesion  of  the  pleurae;  in  the 
other,  a  single  fibre  extended  into,  but  not  through,  an  adhesion  be- 
tween the  liver  and  diaphragm. 

The  time  in  which  these  complete  developments  of  lymph  may  be 
accomplished  must  vary  so  much,  according  to  the  circumstances  of  the 
inflammation,  that  perhaps  no  reasonable  estimate  of  it  can  be  made. 
The  experiments  of  Villerm^  and  Dupuytrenf  upon  dogs  assign  twenty- 
one  days  as  the  earliest  time  in  which  new  vessels  are  formed,  but  I  am 
disposed  to  agree  with  Dr.  Hodgkin,  that  a  shorter  time  is  sufiicient. 
On  the  other  hand,  I  am  sure  that  the  supposition  of  their  being  formed 
in  one  or  two  days  is  incorrect.  The  principal  case  in  support  of  this 
opinion  is  that  recorded  by  Sir  Everard  Home  ;  but  the  specimens  pre- 
served in  the  College  MuseumJ  show  that  he  was  deceived  as  to  the 
true  nature  of  the  case.  He  says§  that  he  operated  for  strangulated 
hernia  in  a  man,  and  found  in  the  sac  a  portion  of  ileum,  which  was 
healthy,  except  in  that  its  vessels  were  turgid  with  blood.  The  patient 
died  twenty-nine  hours  after  the  operation;  and  on  examination  "seve- 
ral small  portions  of  exuded  coagulable  lymph' '  were  found  adhering  to  the 

*  Wiirzbiirg  Verhandlnngen,  i,  144. 

f  Quoted  by  Dr.  Hodgkin,  in  his  Lectures  on  the  Morbid  Anatomy  of  the  Serous  Mem- 
branes, p.  42. 

J  Nos.  81  and  82  in  the  Pathological  Museum. 

§  In  his  Dissertation  on  Pus,  p.  41.  The  whole  case  is  given  in  the  College  Catalogue, 
vol.  i,  p.  37. 


258  DEGENERATIONS    OF    LYMPH. 

intestine  that  had  been  protruded.  When  the  vessels  of  the  intestine 
were  injected,  the  injection  passed  into  vessels  in  all  these  portions  of 
supposed  lymph,  each  "  having  a  considerable  artery  ....  and  a  re- 
turning vein."  Sir  Everard  Home,  therefore,  concludes  "that  the 
whole  operation  of  throwing  out  coagulable  lymph,  and  supplying  it 
with  bloodvessels  after  it  had  become  solid,  was  effected  in  less  than 
twenty-four  hours." 

Now,  one  of  these  specimens  was  figured  by  Mr.  Hunter,*  "  to  show 

a  small  portion  of  coagulating  lymph which  is  supplied  with 

vessels;"  but  neither  here,  nor  in  his  manuscript  catalogue,  does  he 
allude  to  a  probability  of  the  vessels  having  been  formed  in  twenty-four 
hours,  although,  had  he  believed  it  he  would  scarcely  have  failed  to 
record  it.f  An  examination  of  the  specimens  shows  that  the  small, 
shred-like  portions  of  membrane,  attached  by  little  pedicles  to  the  in- 
testine, have  not  the  appearance  of  recently  coagulated  lymph,  but  are 
fully  organized,  with  traces  of  filaments  arid  fat-cells.  They  are  also 
very  regularly  disposed,  at  distances  of  from  half  an  inch  to  an  inch 
from  each  other,  and  are  nearly  all  placed  in  two  rows  on  each  side  of 
the  intestine,  about  half  an  inch  from  the  attachment  of  the  mesentery, 
like  very  minute  appendices  epiploicse,  such  as  •  are  occasionally  met 
with  on  the  coats  of  the  small  intestine.  Whether  they  be  such  appen- 
dices or  not,  it  is  in  the  highest  degree  improbable  that  they  were 
formed  after  the  operation ;  especially  since  they  are  too  minute  and 
delicate  to  have  prevented  the  intestine  from-  exhibiting,  when  exposed 
in  the  sac,  the  natural  polished  appearance  of  its  surface. 

I  am  not  aware  of  any  other  case  adapted  to  prove  the  earliest  period 
at  which  bloodvessels  may  be  formed  in  lymph.  Serous  surfaces  may, 
indeed,  become  adherent  in  twenty-four  hours,  but  this  does  not  imply 
vascularity  of  the  lymph  between  them;  it  is  simply  adhesion  by  the 
coaptation  of  the  intermediate  lymph. 


LECTURE  XYL 

DEGENERATIONS  OF  LYMPH. 

Having  given,  in  the  last  lecture,  a  general  history  of  the  chief  de- 
velopments of  the  lymph  exuded  in  the  inflammatory  process,  I  propose 
now  to  tell  a  corresponding  history  of  its  degenerations ;  and  herein  to 
describe  what  appear  to  be  the  transitions,  from  the  ordinary  forms  of 
lymph  in  its  primary  state,  its  fibrine  and  its  corpuscles,  to  those  many 

*  Works;  pi.  xxi,  fig.  2. 

f  In  the  treatise  on  the  Blood  (Works,  vol.  iii,  p.  350)  he  speaks  of  nine  days  as  a  short 
time  for  the  complete  organization  of  adhesions. 


DEGENERATIONS     OF     THE    FIBRINE     OF    LYMPH.  259 

lower  forms  enumerated  as  molecular  and  granular  matter  ;  as  pus-cells, 
granule-cells,  inflammatory  globules,  and  the  rest. 

I  said  that,  for  the  development  of  lymph  produced  in  inflammation, 
it  is  requisite  that  the  inflammation  shall  have  ceased,  and  the  condi- 
tions of  healthy  nutrition  be  restored.  In  the  failure  of  this  event,  if 
the  inflammation  continue,  or  the  due  conditions  of  nutrition  be  in  any 
way  suspended,  then,  instead  of  development,  degeneration  will  occur, 
with  more  or  less  rapidity,  according  to  the  original  character  of  the 
lymph.  And  this  may  happen  in  any  of  the  stages  of  formation  which 
I  described  in  the  last  lecture :  it  may  happen  alike  to  the  rudimental 
fibrine,  or  to  the  earliest  lymph-cell,  or  to  either,  in  any  part  of  its 
progress  to  complete  development. 

The  following  appear  to  be  the  chief  degenerations  of  the  fibrinous 
part  of  lymph,  or  of  the  materials  derived  from  its  earliest  stages  of 
development,  whether  in  the  purely  fibrinous,  or  in  any  of  the  mixed, 
forms  of  lymph : 

1.  It  may  wither  ;  wasting,  becoming  firmer  and  drier,  passing  into  a 
state  which  Rokitansky  has  designated  liorny.  One  sees  the  best  ex- 
amples of  this  change  of  fibrine  in  the  vegetations  on  the  valves  of  the 
heart,  or  in  the  large  arteries,  when  they  become  yellow,  stiff",  elastic, 
and  nearly  transparent.  The  fibrine  may,  in  this  state,  show  no  marks 
of  development  into  tissue,  but  may  have  all  the  simplicity  of  structure 
of  ordinary  fibrine,  being  only  drier  and  more  compact.  A  nearly 
similar  character  is  acquired  when  lymph  is  deposited  over  a  lung  which 
is  extremely  compressed  in  empyema,  or  in  hydrothorax.  The  tough 
dry  lymph  that  here  forms  the  grayish  layer  over  all  the  lung  is  not 
always  developed,  though  it  may  adhere  firmly  :  it  may  be  withered, 
wasted,  and  dried  (as  the  lung  itself  may  be),  apparently  in  consequence 
of  the  compression. 

2.  The  fibrine  of  lymph  is  subject  to  a  degeneration  which  we  may 
compare  in  many  respects  Avith  fatty  degeneration,  or  more  closely, 
with  the  changes  by  which  lymph-corpuscles  are  transformed  into  those 
of  pus,  with  which  changes,  indeed,  this  is  commonly  associated  in  the 
mixed  forms  of  lymph.  In  the  solid  parts  of  effusions  that  are  found 
in  the  lower  forms  of  inflammation,  or  in  very  unhealthy  persons,  the 
fibrine  of  the  lymph  is  usually  not  clear  and  uniform  and  filamentous, 
but  rather  opaque  or  turbid,  nebulous  or  dotted,  presenting  just  such 
an  appearance  as  marks  the  earliest  stages  of  fatty  degenerations  in 
the  muscular  fibrils.  In  such  lymph,  also,  one  sees,  not  unfrequently, 
minute,  shining,  black-edged  particles,  which  we  may  know  to  be  drops 
of  oil ;  while  some  general  alteration  in  the  composition  of  the  fibrine 
is  shown  by  its  not  being  made  transparent  with  acetic  acid.  In  all 
such  cases  as  these  the  fibrine  is  very  soft,  and  easily  broken  ;  it  is 
devoid  of  all  that  toughness  and  elasticity  which  is  the  peculiar  charac- 
teristic of  well-formed  fibrine ;  and  by  breaking  it  up,  one  may  see  the 
meaning  of  w^hat  one  so  often  finds  in  the  lowest  forms  of  inflammatory 


260  DEGENEHATIONS     OF    THE    FIBRINE    OF    LYMPH. 

exudation,  such  as  occur  in  erysipelas  and  typhus ;  namely,  films  and 
fragments  of  molecular  and  dotted  substance,  floating  in  fluid  that  is 
made  turbid  by  them,  and  by  abundant  minute  molecules  and  granules 
and  particles  of  oily  matter.  These  represent  the  disintegration  of 
fibrine  that  has  degenerated  after  clotting,  or  has  thus  solidified  in  an 
imperfect  coagulation.  Of  such  changes,  also,  an  excellent  instance  is 
presented  in  the  softening  and  disintegration  of  clots  within  the  heart, 
•which  Mr.  Grulliver*  first  described.  These,  indeed,  or  any  of  the  in- 
stances of  the  apparent  suppuration  within  clots  in  the  bloodvessels, 
might  be  studied  for  the  illustration  of  the  corresponding  changes  in 
inflammatory  lymph  ;  especially,  in  relation  to  the  likeness  which,  in 
both  cases,  the  degenerate  fibrine  bears  to  the  molecular  matter  in  the 
thinner  and  more  turbid  kinds  of  pus.f 

We  have  examples  of  numerous  varieties  of  this  degenerate  and  dis- 
integrated fibrine  exuded  in  inflammation.  It  is  a  principal  constitu- 
ent of  most  of  what  has  been  called  "  aplastic  lymph,"  in  inflammation 
of  the  serous  membranes.  Similar  fibrine  occurs,  mingled  Avith  mucus, 
in  the  severer  inflammations  of  the  mucous  membranes.  And  to  the 
same  source  we  may  trace  much  of  that  molecular  and  granular  matter 
which  is  usually  mingled  with  all  the  less  perfect  forms  of  pus :  e.  g. 
with  that  formed  in  the  suppuration  of  chronic  inflammatory  indura- 
tions ;  with  the  variously  changed  corpuscles  of  "  scrofulous  matter  ;" 
or  with  the  granule-cells,  and  other  corpuscles  of  pneumonia,  and  the 
like  inflammations. 

The  general  characters  of  the  materials  here  described,  and  the  coin- 
cident changes  ensuing  in  the  corpuscles  that  may  be  mingled  with  the 
fibrine,  make  it  probable  that  the  changes  are  of  the  nature  of  fatty 
degeneration  occurring  in  the  fibrinous  lymph.  Analogous  to  these 
changes  are  those  which  take  place  in  animal  substances  when  trans- 
planted to  parts  with  which  they  have  normally  no  organic  connection. 
Thus  E.  Wagner|  has  shown  that  a  testicle,  when  engrafted  into  the 
peritoneal  cavity,  goes  through  the  process  of  fatty  degeneration,  and 
that  the  same  change  takes  place  in  the  crystalline  lens,  bits  of  muscle, 
and  even  portions  of  boiled  white  of  egg  when  similarly  treated.  That 
these  changes  are  due  to  an  actual  conversion  of  the  transplanted  sub- 
stance into  fat  appears  to  be  proved  by  the  observations  of  Michaelis,§ 
who  has  noticed  that  the  production  of  ammonia  is  an  accompaniment 
of  the  transformation. 

But  when,  as  I  have  said  elsewhere  (p.  172),  we  see  how  a  large  mass 
of  inflamed  hard  substance  will  become  fluid,  as  it  suppurates,  and  this 
with  scarcely  any,  if  any,  increase  of  bulk,  we  may  believe  that  another 

*  Medico-Chirurgical  Transactions,  vol.  xxii,  p.  136. 

t  We  ought,  doubtless,  with  Mr.  Gulliver,  to  regard  the  corpuscles  found  in  these  cases 
of  softened  clots  vi'ithin  the  heart  as  blood-corpuscles  retained  in  the  clot,  modified  by  stag- 
nation and  concoction. 

X  Nachricht.  der  Gotting.  Acad.  1851.  §  Prajer.  Vierteljahr.  Schrift,  1853. 


DEGENERATIONS     OF    THE     FIBRINE     OF    LYMPH.  261 

change  ensuing  in  the  fibrine  is  that  which  I  called  liquefactive  degene- 
ration (p.  89).  In  such  a  swelling,  we  may  be  nearly  sure  there  is 
coagulated  fibrine,  both  from  the  general  circumstances  of  the  inflam- 
mation, and  because  neither  corpuscles  alone,  nor  fibrine  in  the  liquid 
state,  would  give  such  hardness.  The  suppuration,  therefore,  if  without 
increase  of  bulk,  can  hardly  be  explained,  except  on  condition  of  the 
fibrine,  which  had  solidified,  becoming  again  liquid.  The  occasional 
liquefaction  of  clots  out  of  the  body*  makes  it  more  probable  ;  but  I  am 
not  sure  that  it  can  be  proved  by  any  more  direct  facts. 

A  point  of  some  practical  importance  is  connected  with  these  forms 
of  degeneration  of  lymph,  whether  aifecting  fibrine  or  corpuscles.  When 
the  fibrine  has  withered  and  become  dry,  it  is  probably  put  out  of  the 
capacity  of  being  further  developed,  and  is  rendered  passive  for  further 
harm  or  good,  except  by  its  mechanical  effects.  But  the  fatty  and 
liquefactive  degenerations  may  be  yet  more  beneficial  in  that  they  bring 
the  lymph  into  a  state  favorable  to  its  absorption,  and  therefore  favor- 
able to  that  which  is  termed  the  "■  resolution"  of  an  inflammation  in 
which  lymph  has  been  already  formed.  I  suppose  it  may  be  considered 
as  a  general  truth,  that  the  elements  of  a  tissue  cannot  be  absorbed  so 
long  as  they  retain  their  healthy  state.  There  is  no  power  of  any  ab- 
sorbent vessels  that  can  disintegrate  or  decompose  a  healthy  portion  of 
the  body :  for  absorption,  there  must,  in  general,  be  not  only  an  absorb- 
ing power,  but  also  a  previous  or  concurrent  change, — as  it  were  a  con- 
sent, in  the  part  to  be  absorbed ;  so  that  it  may  be  reduced  (or,  rather, 
may  reduce  itself)  into  minutest  particles,  or  may  be  dissolved.  And 
this  change  is  probably  one  of  degeneration,  not  death,  in  the  part;  for 
dead  matter  is  usually  rather  discharged  from  the  body  than  absorbed. 

I^ow  such  degeneration  of  the  fibrine-products  of  inflammation  as  I 
have  described,  brings  them  into  a  state  most  favorable  for  absorption ; 
indeed,  one  may  see  in  lymph  thus  changed  many  things  which,  in 
regard  to  the  fitness  for  absorption,  make  it  parallel  with  chyle. f  Of 
such  absorption  of  fibrine  we  may  find  many  instances.  In  rheumatic 
iritis  we  may  believe  the  lymph  to  be  fibrinous;  but  we  see  its  complete 
absorption  taking  place ;  and  the  observations  of  Dr.  Kirkes  on  the 
rarity  of  adhesions  of  the  pericardium,  in  comparison  with  the  frequency 
of  pericarditis,!  may  be  in  the  same  manner  explained.  In  rheumatic 
pericarditis  we  may  be  sure  fibrine  is  exuded ;  and  the  observed  friction- 
sound  has,  in  some  cases,  proved  its  coagulation ;  yet  in  these  cases, 
when  death  occurred  months  afterwards,  scarce  a  trace  of  fibrine  was 
found  in  the  pericardium  :  it  had  been  absorbed,  and  the  degeneration 
I  have  been  describing  was  probably  the  preparation  for  its  absorption. 

*  As  in  cases  by  Nasse  and  De  la  Harpe,  quoted  by  Henle,  in  his  Zeitschrift,  B.  ii,  p.  169. 
See  also  Virchow  on  the  same  subject,  in  the  same  Zeitschrift,  B.  iv.  Henle  refers  to  this 
same  liquefaction  the  changes  that  ensue  in  emitted  semen. 

t  See  also  the  ingenious  contrast  of  the  progress  of  chyle  and  the  regress  of  pus  drawn 
by  Gerber,  in  his  Allgem.  Anatomic,  p.  49. 

J  Medical  Gazette,  April,  1849. 


262 


DEGENERATIOiS^S     OF    THE    FIBRINE     OF    LYMPH. 


3.  I  am  not  aware  of  any  direct  proof  of  the  calcareous  degeneration 
ensuing  in  the  fibrinous  part  of  an  inflammatory  exudation ;  but  we  have 
the  strongest  evidence  from  analogy  for  believing  that  this  change  may 
be  a  frequent  one.  For  there  are  numerous  instances  of  calcifications 
of  fibrine  within  the  vessels  :  as,  e.  g.  in  the  ordinary  formation  of  phle- 
bolithes  from  clots  of  blood,  in  the  branching  and  irregular  pieces  of 
bone-like  substance  found  in  obliterated  veins,  and  in  the  lumps  and 
grains  of  substance  like  mortar  imbedded  in  fibrinous  deposits  on  the 
heart's  valves.  We  can,  therefore,  hardly  doubt  that  the  fibrine,  even 
before  development,  may  take  part  in  formations  of  earthy  matter  in 
inflammator}^  products ;  but  the  calcareous  degeneration  seems  much 
more  frequent  in  purulent  fluids,  and  in  the  later  developments  of 
lymph. 

4.  Lastly,  we  have  examples  of  the  pigmental  degenerations  of 
fibrinous  lymph  in  the  various  shades  of  gray  and  black  which  often 
pervade  the  lymph  formed  in  peritonitis,  and  which  are  produced,  not 
by  staining  or  discoloration  of  the  blood  by  intestinal  gases,  but,  accord- 
ing to  Rokitansky,  by  the  incorporation  of  free  pigment-granules. 

Such  appear  to  be  the  degenerations  of  the  fibrine  of  inflammatory 
lymph :  such,  at  least,  are  the  changes  in  it  which  we  may  refer  to  de- 
fects in  its  power  or  conditions  of  nutrition,  because  they  correspond 
with  changes  that  may  be  traced  in  the  gradual  degenerations  of  old 
age.  I  need  hardly  say,  that  it  is  chiefly  by  such  correspondence  that 
we  can  interpret  them  ;  for  when  we  find  them,  it  is  often  beyond  our 
power  to  tell,  by  direct  observation,  whether,  or  in  what  way,  the  con- 
ditions of  nutrition  were  defective. 

The  corpuscular  constituents  of  lymph,  in  any  of  their  stages  of  de- 
velopment, may  retrograde,  and  present  degenerations  corresponding 
and  usually  concurrent  with  those  which  I  have  just  described. 

1.  Their  withering  is  well  seen  in  some  forms  of  what  is  called  scro- 
fulous matter,  such  as  occur  in  chronic  and  nearly  stationary  scrofulous 
enlargements  of  lymphatic  glands.  In  the  dull  ochre-yellow  colored, 
and  half  dry  material,  imbedded  in  such  glands,  may  be  found  abundant 
cells,  such  as  are  sketched  in  Fig.  36.     They  are  collapsed,  shrivelled, 

Fig.  36. 


wrinkled,  glistening,  and  altogether  irregular  in  size  and  form.  One 
might  suppose  them  to  be  the  remnants  of  pus  dried  up,  or  the  corpus- 
cles of  chronic  tuberculous  matter,  if  it  were  not  that  among  them  are 
some  with  nuclei  shrivelled  like  themselves,  and  some  elongated  and 


DEGENERATIOlSrS    OP    THE    COEPUSCLES    OP    LYMPH. 


263 


attenuated,  which  are  evidently  such  as  withered  after  they  had  been 
developed  into  the  form  of  fibro-cells ;  into  which  form  it  is  certain 
that  neither  pus-corpuscles  nor  those  of  tubercle  are  ever  changed. 

These  are  the  best  examples  of  withered  lymph-corpuscles  ;  but  they 
may  be  also  found  in  the  pus  of  chronic  abscesses,  especially,  of  course, 
in  that  of  such  abscesses  as  ensue  by  suppuration  of  lymph-deposits 
like  those  just  referred  to.  It  may  be  hard,  sometimes,  to  say  whether 
corpuscles  in  these  cases  may  not  be  pus-corpuscles  shrivelled  up  :  but 
on  the  whole,  1  am  inclined  to  believe  that  the  shrivelled  corpuscles  of 
the  pus  of  chronic  abscesses  are  usually  derived  from  the  lymph,  in 
which,  having  withered,  they  had  become  incapable  of  further  change. 

2.  The  fatty  degeneration  of  lymph-cells  is  shown  in  their  transition 
into  granule-cells — the  inflammatory  globules  of  Gluge.  "We  owe  the 
first  demonstration  of  this  to  the  excellent  observations  of  E-einhardt,* 
who  has  also  shown  how,  by  similar  degenerations,  corresponding  forms 
of  granule-cells  may  be  derived  from  the  primary  cells  of  almost  all 
other,  both  normal  and  abnormal,  structures. f 

This  method  of  degeneration  appears  peculiarly  apt  to  occur  in  the 
inflammations  of  certain  organs  ;  as,  especially,  the  lungs,  brain,  and 
spinal  cord  ;  but  it  may  be  found  occasionally  prevalent  in  the  lymph 
of  nearly  all  other  parts,  and  in  the  granulations  forming  the  walls  of 
abscesses  or  of  fistulae.  It  may  occur  alike  in  the  early  forms  of  lymph- 
cells,  and  after  they  have  already  elongated  and  attenuated  themselves, 
as  if  for  the  formation  of  filaments,  and  after  they  have  degenerated 
into  pus-cells.  The  changes  of  transition  (as  shown  in  fig.  37)  are, 
briefly,  these :  The  lymph-cells,  which  may  have  at  first  quite  normal 
characters,  such  as  I  have  described  (p.  234),  present  a  gradual  increase 


Fig.  37. 


^^^ 


of  shining,  black-edged  particles,  like  minute  oil-drops,  which  accumu- 
late in  the  cell-cavity,  and  increase  in  number,  and  sometimes  in  size 
also,  till  they  nearly  fill  it.  The  fatty  nature  of  these  particles  is 
proved  by  their  solubility  in  ether :  and  their  accumulation  is  attended 
with  a  gradual  enlargement  of  the  cell,  which  also  usually  assumes  a 
more  oval  form.  Moreover,  while  the  fatty  matter  accumulates,  the 
rest  of  the  contents  of  the  cell  become  very  clear,  so  that  all  the  inter- 


*  Traube's  Beitrage,  B.  ii,  277. 

f  Observations  similar  to  part  of  those  of  ReinharcU  were  made  independently  by  Dr. 
Andrew  Clark.  (Medical  Gazette,  vols,  xlii,  xliii.)  See  also  Dr.  Gairdner's  description  of 
the  formation  of  granule-cells  from  epithelium-cells  in  pneumonia  (Contributions  to  the 
Pathology  of  the  Kidney,  p.  20)  ;  and  the  list  of  references,  p.  119. 


264      DEGENERATIONS    OF    THE     CORPUSCLES     OF    LYMPH. 

spaces  between  the  particles  are  quite  transparent ;  and,  coincidently 
with  all  these  changes,  the  nucleus  gradually  fades  and  disappears,  and 
the  cell-wall  becomes  less  and  less  distinct. 

I  need  hardly  say,  that,  in  these  particulars,  the  changes  of  the 
lymph-cells  (which  may  also  occur  when  they  have  been  already  de- 
veloped into  the  form  of  fibro-cells),  correspond  exactly  with  those  of 
the  fatty  degenerations  observed  in  the  cells  of  the  liver  or  kidney,  or 
in  the  fibres  of  the  heart.  There  can  be  hardly  a  doubt  of  the  nature 
of  this  process :  and  it  presents  an  important  parallel  with  the  similar 
changes  described  in  fibrine.  For,  we  may  observe,  first,  that  where 
this  degeneration  is  apt  to  occur  in  lymph,  it  is  least  likely  to  be  de- 
veloped. A  proper  induration  and  toughening  of  the  lungs  and  brain, 
such  as  might  happen  through  development  of  the  products  of  inflamma- 
tion, is  extremely  rare ;  it  is  rarely  seen,  except  in  the  scars  by  which 
the  damages  of  diseases  are  healed.  And,  besides,  this  degeneration  is  a 
step  towards  the  absorption  of  the  lymph ;  for  commonly  we  may  trace 
yet  later  stages  of  degeneration  in  these  granule-cells.  They  lose 
their  cell-walls,  and  become  mere  masses  of  grainules  or  fatty  particles, 
held  together  for  a  time  by  some  pellucid  substance,  but  at  last  break- 
ing up,  and  scattering  their  components  in  little  clusters,  or  in  separate 
granules. 

Thus,  if  at  no  earlier  period  of  their  existence,  or  after  no  fewer 
changes,  the  lymph-corpuscles  may  pass  into  a  condition  as  favorable 
for  absorption  as  is  that  of  the  fibrine  when  similarly  degenerate  and 
broken  up :  and  such  as  this,  we  may  believe,  is  a  part  of  the  process 
by  which  is  accomplished  that  "clearing  up"  of  parts  indurated  and 
confused  in  inflammation,  and,  especially,  that  of  the  solidified  lung, 
which  is  watched  with  so  much  interest  in  pneumonia. 

3.  Calcareous  degenerations  of  the  lymph-cells  appear  in  cases,  such 
as  Henle*  refers  to,  in  which  granule-cells  are  composed  not  wholly  of 
fatty  matter,  but  in  part  also  of  granules  of  earthy  matter.  In  this 
combination  they  correspond  with  a  common  rule  ;  for  the  fatty  and 
earthy  degenerations  are  usually  coincident :  they  are  combined  in  the 
advanced  stages  of  the  degenerations  of  arteries,  and  may  be  said  to 
have  their  normal  coincidence  in  ossification. 

4.  Of  the  pigmental  degeneration  of  lymph-cells  there  are,  I  sup- 
pose, examples  in  the  black  matter  efi"used  in  peritonitis :  but  the  best 
examples  are  in  the  cells  in  bronchial  mucus,  to  which  I  have  already 
referred  (Fig.  33). 

The  most  frequent  degeneration  of  inflammatory  lymph  is  into  pus. 
It  may  ensue  in  nearly  all  the  cases  in  which  lymph  is  placed  in  condi- 
tions unfavorable  to  its  development ;  as  in  the  persistence  of  inflamma- 
tion, or  in  exposure  to  air,  or  in  general  defects  of  vital  force.     It 

*  In  his  Zeitschrift,  B.  ii. 


INFLAMMATORY    SUPPURATION.  265 

affects  alike  the  fibrinous  and  the  corpuscular  parts  of  lymph.  For 
although  we  do  not  call  any  liquid  "pus,"  unless  it  have  the  charac- 
teristic pus-corpuscles,  yet  the  materials  of  degenerate  fibrin e  are  com- 
monly mixed  with  these  ;  and  indeed  many  of  the  varieties  of  the  pus 
formed  in  inflammations  owe  their  peculiarities  to  the  coincident  de- 
generations of  the  fibrine. 

The  changes  which  seem  to  prove  the  transformation  of  inflammatory 
lymph  into  pus  correspond  very  nearly  with  those  already  cited  (p.  170) 
concerning  the  similar  relations  of  granulations  to  pus  in  the  process  of 
repair.     But  a  few  may  be  mentioned  here : 

1.  The  fluid  of  such  vesicles  as  those  of  herpes,  is,  in  the  first  in- 
stance, a  pure  inflammatory  lymph,  containing  corpuscles  which  might 
be  taken  as  types  of  the  lymph  or  exudation-corpuscles,  and  which  may 
be  as  easily  llistinguished  from  any  cells  of  pus,  as  the  cells  of  well- 
formed  granulations  may  be.  If  we  watch  these  vesicles,  we  see  their 
contents  not  increased, — rather,  by  evaporation,  they  are  diminished; 
but  the  lymph  is  converted  into  pus,  and  pus-cells  are  now  where  lymph- 
cells  were.  And  the  change  may  ensue  very  quickly :  I  think  I  have 
known  it  accomplished  in  twelve  hours  at  the  most.* 

2.  In  like  manner,  as  I  said  before  (p.  172),  when  we  watch  the  pro- 
gress of  an  abscess,  we  may  find  one  day  a  circumscribed,  hard,  and 
quite  solid  mass,  and  in  a  few  days  later  the  solid  mass  is  fluid,  and 
this  with  little  or  no  increase  of  bulk.  Now,  the  solidity  and  hardness 
are  due  to  inflammatory  lymph ;  the  later  fluid  is  pus,  and  the  change 
is  the  conversion  of  lymph  into  pus. 

3.  As  in  common  suppuration  of  a  granulating  wound,  the  granula- 
tion-cells appear  to  be  convertible  into  pus-cells,  superficial  cells  being 
detached  in  pus,  while  deeper  ones  seem  as  if  developing  into  filaments  ; 
and  as  in  worse  formed  granulations,  the  cells  are  often  by  no  charac- 
ters, except  by  their  forming  a  solid  tissue,  distinguishable  from  pus- 
cells  ;  so,  in  an  inflamed  serous  membrane,  pus-cells  may  float  in  the 
fluid,  such  as  cannot  be  distinguished  from  cells  in  the  vascularized 
lymph  that  lines  the  cavity.  In  the  fluid  exudation,  and  in  that  which 
is  solid,  the  same  forms  may  be  found ;  though,  by  comparison,  we  may 
be  able  to  trace  that  in  the  former  none  of  the  cells  were  being  developed, 
and  many  were  proceeding  beyond  the  degeneration  to  which  any  had 
attained  in  the  latter. 

4.  One  may  see  the  same  conversion  of  inflammatory  lymph  into  pus 
thus  illustrated.  An  amputation  through  the  thigh  was  performed  when 
all  the  parts  divided  were  infiltrated  with  lymph,  effused  in  connection 
with  acute  traumatic  inflammation  of  the  knee-joint.  Next  day  pus 
flowed  freely  from  the  wound.  Now,  in  amputation  through  healthy 
tissues,  free  suppuration  does  not  appear  till  after  three  or  four  days : 

*  It  may  be  that  the  lymph  and  pus-cells  formed  in  these  cases  are  derived  from  the 
nuclei  of  the  cells  of  the  deeper  epidermal  layers.     See  note,  p.  235. 

18 


266  INFLAMMATORY    S  UPPU  E  AT  ION. 

the  pus  here  seen  must  have  been  formed  by  the  conversion  of  the  in- 
flammatory lymph  previously  infiltrated  in  the  divided  tissues.  Similar 
facts  may  be  less  strikingly  observed  in  any  wound.* 

*  Since  the  delivery  and  publication  of  these  lectures,  much  has  been  written  on  the  sub- 
ject of  suppuration  and  the  origin  of  pus,  which  tends  to  throw  a  new  light  on  many  of  the 
pathological  changes  discussed  in  this  and  others  of  these  lectures.  It  is  by  Professor  Vir- 
chow,  and  the  school  of  pathologists  of  which  he  is  the  chief  expositor,  that  most  of  the  in- 
vestigations have  been  made,  which  render  necessary  a  modification  of  some,  at  least,  of  our 
former  views  on  this  question.  From  a  very  extended  series  of  observations  conducted  on 
most  of  the  textures  and  organs  of  the  body,  it  would  appear,  that  a  free  exudation  of  lymph 
into  or  amongst  them  is  not  an  essential  preliminary  to  the  process  of  suppuration,  and  that 
when  such  an  exudation  does  take  place,  the  pus-cells  do  not  arise  in  it  by  any  mere  aggre- 
gation of  granules  and  visible  molecules — by  a  spontaneous  free  cell  formation — as  is  some- 
times described,  but  that  the  pus  proceeds  from  peculiar  formative  changes  in  the  cellular 
and  nuclear  elements  of  the  parts  themselves.  To  render  such  a  theory  at  all  probable,  it 
was  necessary  to  show  that  a  wide-spread  diffusion  of  cellular  or  nuclear  structures  existed 
in  the  midst  of  the  textures  in  their  completed  state.  These  had  long  been  known,  in  many 
localities,  as  muscle,  nerve,  cartilage,  epithelium,  and,  as  was  pointed  out  by  Professor  Good- 
sir,  in  bone  itself.  It  is  in  the  connective  tissue,  however,  in  its  various  forms  and  modifi- 
cations, that  they  have  of  late  years  been  particularly  recognized,  and  it  is  in  their  relations 
to  this  important  texture  that  the  observations  of  Virchow  especially  apply.  For,  from  the 
extensive  distribution  of  the  connective  tissue  in  all  parts  of  the  body,  not  merely  in  its  spe- 
cial forms  of  tendons,  ligaments,  fascia,  aponeuroses,  but  from  its  relations  to  bone  and  car- 
tilage, from  its  presence  in  the  muscular  and  nervous  textures,  in  skin,  mucous,  and  serous 
membranes,  from  its  forming  a  more  or  less  continuous  framework  in  which  the  vascular, 
tubular,  and  epithelial  elements  of  the  various  glands  are  imbedded,  it  constitutes  undoubt- 
edly one  of  the  most  important  tissues  of  the  body,  and  supplies  us  with  a  source  from  which 
such  cellular,  or  nuclear,  structures  may  be  derived. 

Many  experiments  and  observations  have  now  demonstrated  that  when  pus  forms  in  a 
deep-seated  part  it  is  preceded  and  accompanied  by  changes  in  the  cellular  elements  of  the 
connective  tissue  of  that  part,  and,  in  some  cases,  even  in  the  nuclei  of  the  muscular  and 
nervous  tissues  also.  These  changes  consist  in  an  elongation  and  subsequent  division  of  the 
nucleus,  so  that,  where  but  a  single  nucleus  existed  in  the  normal  state,  now  crowds  may  be 
observed.  In  the  course  of  time  these  assume  the  appearance  of  pus-corpuscles.  The  hard, 
solid  feel  which  a  part  always  possesses  diu'ing  the  early  stage  of  formation  of  an  abscess, 
is  occasioned  by  the  multiplication  or  proliferation  of  the  nuclei,  whilst  the  soft,  fluctuating 
later  stage  is  due  to  the  separation  from  each  other  of  these  nuclei,  now  changed  into  pus- 
cells,  by  a  fluid  intercellular  substance.  Again,  when  pus  forms  in  the  epidermis,  or  on  the 
surface  of  a  mucous  or  serous  membrane,  it  may  be  produced  either  from  the  sub-epithelial 
connective  tissue  cells,  or  it  may  arise  in  an  endogenous  manner  in  the  epithelial  cells  them- 
selves. In  the  latter  case  the  epithelial  cells  burst,  and  the  pus-corpuscles,  formed  in  the 
interior,  are  set  free. 

The  observations  on  which  the  statements  made  in  this  note  are  founded  are  recorded  by 
J.  Goodsir  (Anat.  and  Path.  Observations,  1845),  Virchow  (Cellular  Pathologic,  1858),  Bill- 
roth (Beitrage  zur  Path.  Hist.,  1858),  in  the  later  volumes  of  Virchow's  Archiv — by  Buhl, 
Bottcher,  Forster,  C.  0.  Weber,  Rindfleisch,  Burckhardt,  Sczelkow,  Hjelt,  and  Cohnheim,  and 
by  Haldane,  in  Edin.  Med.  Journal,  November,  1862,  by  whom  investigations  have  been  made 
on  suppuration  in  bone,  cartilage,  the  fibrous,  muscular,  and  nervous  tissues,  skin,  mucous  and 
serous  membranes. 

The  Editor  has,  also,  from  a  series  of  observations  made  on  an  inflamed  pleura,  observed 
appearances  which  satisfied  him  that  proliferation  of  the  nuclei  of  the  connective  tissue-cor- 
puscles of  the  serous  membrane  was  taking  place.  His  examination  was  conducted  on  sec- 
tions made  through  the  inflamed  membrane  at  right  angles  to  the  surface.  The  inflammatory 
lymph  on  the  free  surface  of  the  pleura  was  soft,  yellowish,  and  evidently  but  recently  pro- 
duced.    It  was  composed  almost  entirely  of  cells,  the  structureless  or  dimly  granular  in- 


ABSCESS.  267 

From  these  and  the  like  facts  we  have  an  almost  exact  parallel,  in 
their  relations  to  pus,  between  the  material  for  repair  by  granulations 
and  that  exuded  in  the  inflammatory  process  ;  and  between,  if  they 
may  be  so  called,  the  reparative  and  the  inflammatory  suppurations. 
And  in  some  of  the  facts  we  may  trace  a  transition  from  the  one  process 
to  the  other.  In  the  formation  of  an  acute  abscess,  for  example,  in- 
flammatory lymph  is  transformed  into  pus ;  then  the  pus,  say,  is 
discharged;  the  signs  of  inflammation  cease;  the  process  of  repar  is 
established,  and  reparative  granulations  line  the  abscess-cavity  in  the 
place  of,  or  formed  by,  the  peripheral  layer  of  the  lymph.  Now,  pus 
continues  to  be  formed :  but  this  pus  is  derived,  not  from  inflammatory 
lymph,  but  from  granulation-substance.  So,  also,  when  an  inflamed 
part  is  cut,  the  first  pus  is  from  lymph :  the  latter  pus,  when  repair  is 
in  progress,  is  from  granulation-substance.  In  both  cases,  alike,  the 
pus  manifests  itself  as  a  rudimental  substance  ill-developed  or  dege- 
nerated (see  p.  171) ;  and  the  transition  from  the  one  condition  to  the 
other  is  an  evidence  of  the  impossibility  of  exactly  defining  between  the 
inflammatory  and  the  reparative  processes,  unless  we  can  see  their  de- 
sign and  end. 

Much,  therefore,  of  what  was  said  respecting  suppuration  in  connec- 
tion with  repair,  might  be  repeated  here.  But,  avoiding  this,  let  me 
only  point  out  the  principal  methods  in  which  inflammatory  suppuration 
ensues,  and  the  relation  of  the  pus  in  each  to  the  previous  or  coincident 
inflammatory  product.  In  this  last  respect,  the  suppuration  of  disease 
differs  in  an  important  manner  from  that  of  the  reparative  process,  in 
that  the  degeneration  may  take  place  in  any  of  the  difi"erent  varieties  of 
lymph,  and  that,  according  to  the  primary  character  of  the  lymph,  there 
may  be  traced  (though  as  yet  too  obscurely)  different  appearances  of 
the  pus.* 

The  methods  of  such  suppuration  may  be  named  the  circumscribed, 
the  diff'use,  and  the  superficial.  The  first  may  be  exemplified  by  the 
formation  of  an  abscess  or  a  pustule ;  the  second  by  phlegmonous  ery- 
sipelas, or  purulent  infiltration  of  any  organ ;  the  third  by  purulent 
ophthalmia,  or  gonorrhoea :  and  in  these  and  the  like  instances  we  may 

tercellular  substance  being  at  a  minimum.  The  proper  epithelial  covering  of  the  pleura  had 
altogether  disappeared.  The  corpuscles  of  the  subjacent  connective  tissue  were  evidently 
much  changed  from  their  normal  state.  They  were  swollen,  and  presented,  in  their  interior, 
some  two,  others  a  larger  number,  occasionally  half  a  dozen,  of  distinct,  pale,  faintly  granular, 
circular  or  oval  bodies,  closely  corresponding,  in  form  and  general  aspect,  to  the  corpuscles 
of  the  inflammatory  lymph.  These  were,  without  doubt,  derived  by  division  from  the 
original  nuclei  of  the  connective  tissue  cells.  In  different  parts  of  the  tissue  might  be  traced 
the  gradations  of  this  process:  from  cells,  where  the  multiplication  was  evidently  only  com- 
mencing, to  others,  where  it  had  advanced  to  such  an  extent  that  crowds  of  the  new-formed 
structures  existed,  so  as  to  obscure  more  or  less  completely  the  proper  characters  of  the  texture. 
Additional  observations  made  on  an  inflamed  mucous  membrane,  in  a  case  of  inflammation 
of  the  pelvis  of  the  kidney  and  ureter,  have  also  afforded  results  of  a  closely  corresponding 
nature. 

*  See  especially  Rokitansky :  Pathol.  Anat.  B.  i,  p.  210. 


268  ABSCESS. 

often,  at  the  close  of  the  disease,  watch  the  transition  from  the  suppura- 
tion that  depends  on  the  inflammatory  process,  to  that  which  is  coin- 
cident with  repair. 

In  circumscribed  suppuration,  which  has  its  most  usual  seat  in  the 
areolar  tissue,  we  can  generally  observe  the  previous  signs  of  inflam- 
mation, and  of  exudation  of  lymph  in  a  certain  area  of  the  tissue.  The 
exudation  is  interstitial,  or  by  infiltration ;  and,  probably,  in  most 
acute  abscesses,  is  of  a  mixed  kind,  containing  both  fibrine,  which  may 
solidify,  and  a  liquid  material.  The  proper  elements  of  the  tissue  are 
separated  or  expanded  by  the  lymph  thus  inserted  among  them ;  and 
the  inflamed  part  derives  from  it  much  of  its  swelling,  and  much  of  its 
hardness,  while  the  fibrinous  part  of  the  lymph  is  solid.  Generally, 
such  a  swelling  is  at  first,  comparatively,  ill-defined  ;  and  if  it  be  near 
the  skin,  the  visible  inflammatory  redness  very  gradually  fades  out  at 
its  borders,  where,  in  the  deeper  tissue,  we  may  believe,  the  exudation 
is  gradually  less  abundant.  But,  in  time,  the  swelling  usually  becomes 
more  defined ;  the  inflammation,  as  it  were,  concentrates  itself,  and  ap- 
pears more  completely  circumscribed.  Now  the  lymph,  in  such  a  case, 
may  be  absorbed,  or  may  be  developed  so  as  to  form  a  long-continuing 
thickening  and  induration  of  the  part :  but,  in  the  case  I  am  supposing, 
it  is  transformed  into  pus  ;  its  corpuscles  changing  their  characters  in 
the  manner  already  described,  and  a  portion,  perhaps,  of  its  previously 
solidified  part  becoming  liquid.  The  change  almost  always  begins  at  or 
near  the  centre  of  the  lymph,  where,  we  may  believe,  the  conditions  of 
nutrition  are  most  impaired.  It  may  extend  from  a  single  point,  or 
from  many  which  subsequently  coalesce.  In  either  case  the  central 
collection  of  matter  remains  surrounded  by  a  border  or  wall  of  indurated 
tissue,  in  which  the  infiltrated  lymph  is  not  transformed  into  pus,  but, 
rather,  tends  to  be  more  highly  organized.  This  border  or  peripheral 
layer  of  lymph  now  forms  the  wall,  as  it  is  called,  of  the  abscess,  and 
the  finger  may  detect,  as  the  best  sign  of  abscess,  a  soft  or  fluctuating 
swelling  with  a  firm  or  hard  border.  The  expressions  commonly  used 
are,  that  the  suppurative  inflammation  has  taken  place  in  the  centre  of 
the  swelling,  and  that  its  efi'ects  are  bounded  by  the  adhesive  inflamma- 
tion :  it  might  be  said,  with  the  same  meaning,  but  perhaps  more  clearly, 
that,  of  a  certain  quantity  of  lymph  produced  in  the  original  area  of 
the  inflammation,  the  central  portions  have  degenerated  into  pus,  and 
the  peripheral  have  been  maintained  or  more  highly  developed :  and 
probably,  we  may  add  in  explanation,  the  diff'erence  has  depended  on 
the  degrees  in  which  the  conditions  of  nutrition  have  been  interfered 
with  in  the  places  in  which  the  two  portions  have  been  seated.  In  the 
central  parts  of  an  inflammatory  swelling,  the  circulation,  if  not  wholly 
arrested,  must  be  less  free  than  in  the  peripheral ;  the  blood,  moving 
very  slowly  or  stagnant,  must  lose  more  of  its  fitness  for  nutrition ;  the 
tissues  themselves  are  more  remote  from  the  means  of  maintenance  by 
imbibition  :  in  these  parts,  therefore,  degeneration,  if  not  death,  ensues ; 


ABSCESS. 


269 


■while,  in  the  peripheral  parts,  maintenance,  or  even  development,  is  in 
progress.* 

Now,  in  the  ordinary  course  of  such  an  abscess,  the  purulent  matter 
is  discharged.'  (I  shall  speak  in  the  next  lecture  of  the  manner  in 
which  this  takes  place,  as  well  as  of  the  changes  that  ensue  in  the  tis- 
sues among  whose  elements  the  lymph  is  infiltrated.)  On  the  interior 
of  its  wall,  especially  if  its  course  have  been  very  acute,  we  may  find  a 
thin,  opaque,  yellowish-white  layer,  easily  to  be  detached,  flaky,  or 
grumous.  It  is  usually  formed  of  lymph-cells  or  pus-cells  imbedded  in 
flakes  of  soft  fibrinous  substance.  It  has  been  made  to  seem  more  im- 
portant than  it  is,  by  being  called  by  some  a  "pyogenic  membrane," 
and  by  its  being  supposed  that  it  is  the  work  of  the  cells  to  secrete  the 
pus.  But  the  existence  of  such  a  layer  is  far  from  constant  in  abscesses  ; 
it  is,  often,  a  sign  of  the  imperfect  organization  of  the  abscess-wall ;  its 
materials  are  probably  oftener  detached  and  mingled  with  the  pus  than 
they  are  vascularized  ;  and  no  such  layer  is  found  when  free  suppuration 
continues  in  an  open  abscess.  A  more  normal  course  is  observed  when 
the  progress  of  suppuration  has  been  slower.  In  this  case,  the  wall  of 
the  abscess  becomes  more  highly  organized  after  the  discharge  of  the 
contents ;  the  circulation  being  restored  in  the  infiltrated  tissues  of 
which  the  wall  is  formed,  the  lymph  is  developed,  or  at  least,  if  I  may 
so  speak,  more  highly  vivified,  and  its  cells,  or  new  ones  formed  next 
to  the  abscess-cavity,  are   constructed  into  granulations,  and  are  sup- 

Fiff.  38. 


plied  with  bloodvessels,  like  those  on  the  surface  of  a  healing  suppura- 
ting wound.     Such  vessels  are  represented  in  the  sketch.     (Fig.  38.) 
With,  or  soon  after,  the  evacuation  of  the  purulent  matter,  the  dis- 


*  Expressions  are  sometimes  used  which  imply  that  the  wall  of  the  abscess  is  formed  by 
an  adhesive  inflammation  following,  and  purposely  consequent  on,  the  suppurative.  This 
certainly  happens,  if  ever,  very  rarely  :  it  only  seems  to  take  place  when  suppuration  is  ac- 
companied by  extending  inflammation.  In  sucli  a  case,  that  which  is  to-day  the  indurated 
abscess-wall,  may,  to-morrow,  have  become  pus;  and  new  inflammatory  products,  formed 
around  it  during  its  degeneration,  will  form  then,  the  boundary  of  the  enlarged  abscess.  It 
may  be,  indeed,  that  the  lymph  situated  at  the  centre  of  the  inflammatory  process  is,  natu- 
rally, less  organizable  than  that  at  the  periphery;  but  this  is  not  proved. 


270  DIFFUSE    SUPPURATION. 

ease  on  which  the  abscess  depended  may  cease  :  and,  if  this  be  so,  the 
later  progress  of  the  case  is  a  process  of  healing  which  may,  in  every 
essential  character,  be  likened  to  the  healing  of  a  wound  by  granula- 
tion. There  is  the  same  gradual  development  of  the  lymph-cells,  or,  as 
they  might  now  be  called,  the  granulation-cells  of  the  walls  of  the  ab- 
scess,— first  of  the  deeper,  and  then  of  the  more  superficial  cells.  The 
same  contraction,  also,  attends  this  process,  and  serves  to  diminish  the 
area  of  the  cavity,  and  to  bring  its  walls  more  nearly  into  correspon- 
dence and  proximity  with  the  external  opening,  till,  coming  into  con- 
tact, the  opposite  surfaces  of  granulations  may  unite,  as  in  healing 
by  secondary  adhesion ;  or  till,  as  the  edges  of  the  opening  are  retracted 
and  depressed,  and  the  floor  of  the  abscess  is  raised,  they  are  brought 
nearly  to  a  level,  and  heal  as  a  single  granulating  surface. 

Such  an  abscess  as  I  have  described  is  often  called  acute  or  phleg- 
monous, in  contradistinction  from  those  collections  of  pus  which,  being 
formed  without  the  observed  ^  signs  of  inflammation,  and  generally 
slowly,  are  named  cold  or  chronic  abscesses.  Observations  are  wanting, 
I  believe,  which  might  show  how  far  the  chronic  abscesses  diff'er  from 
such  as  I  have  described  in  their  early  condition  ;  and,  especially, 
whether  there  be  first  a  circumscribed  infiltration  of  lymph,  of  which 
part  degenerates  and  the  rest  is  developed.  It  is  probable  the  phe- 
nomena are  essentially  the  same ;  for  instances  of  all  possible  grada- 
tions between  the  two  forms  may  be  observed ;  and,  in  the  complete 
state  of  the  chronic  abscess,  the  structures  are  not  widely  difi'erent  from 
those  of  the  acute.  The  abscess-wall  is  usually  firmer,  more  defined, 
so  that  it  can  often  be  dissected  entire  from  the  adjacent  parts,  and  has 
its  tissue  more  developed,  and  jaxore  like  those  of  a  membranous  cyst : 
the  lining  is  generally  less  vascular,  smoother,  and  less  distinctly  granu- 
lated ;  the  contents  are  usually  thin  and  serous,  and  indicate  not  only 
that  the  material  of  which  they  are  composed  was  peculiarly  unapt  to 
be  organized,  but  that,  even  after  its  transformation  into  pus,  further 
degenerations  ensued  in  it. 

The  difiuse  suppuration,  as  I  have  said,  may  be  exemplified  by  phleg- 
monous erysipelas.  Here,  with  well-marked  phenomena  of  inflamma- 
tion, lymph  is  exuded  through  a  wide  extent  of  the  subcutaneous  areolar 
tissue,  and,  from  first  to  last,  the  boundaries  of  the  exudation  are  ill- 
defined:  the  suppuration  is,  indeed,  most  certain  and  complete  at  the 
centre,  or  where  the  inflammation  began  ;  but  it  may  be  nearly  coex- 
tensive with  the  exudation,  and  most  rarely  presents  a  well-defined 
boundary-wall,  as  in  abscess.  The  lymph,  in  its  primary  character,  is 
mixed ;  its  fibrinous  constituent  is  evident  in  the  coagulation  that  en- 
sues when  it  is  let  out  (see  p.  230),  and,  usually,  in  the  abundant  molecu- 
lar matter  in  the  pus.  The  exudation  is  even  more  distinctly  interstitial 
than  in  an  abscess ;   the  tissue  is  thoroughly  infiltrated  with  it,  and  is, 


SUPERFICIAL     SUPPURATION.  271 

comparatively,  little  expanded :  and  when  suppuration  has  ensued,  and 
we  cut  into  the  inflamed  parts,  the  pus  often  flows  out  slowly,  even  re- 
mains entangled  in  the  tissue.  The  same  condition  is,  often,  yet  more 
plain  in  the  purulent  infiltrations  of  such  organs  as  the  lungs  ;  their  tis- 
sues are  completely  soaked  with  pus.  The  infiltrated  tissues  themselves 
are  usually  softened,  not  only  by  the  mixture  of  the  unorganized  in- 
flammatory matter,  but  through  their  own  degeneration :  and,  very 
generally,  large  portions  of  them  perish,  and  are  found  as  sloughs  in- 
filtrated with  pus. 

In  regard  to  their  structural  changes,  there  may  appear  little  differ- 
ence between  this  condition  and  that  of  acute  abscess,  except  in  the 
contrast  of  the  one  being  less,  the  other  more  circumscribed.  But  in 
regard  to  the  materials  exuded,  they  are,  probably,  in  the  phlegmonous 
erysipelas,  much  less  naturally  apt  for  organization  than  in  the  abscess. 
The  central  suppuration  of  an  abscess,  while  the  lymph  around  is  or- 
ganizing, implies  that  the  degeneration  depends  much  on  the  local  de- 
fect of  the  conditions  of  nutrition  :  the  difiuse  suppuration  seems  due, 
in  a  larger  measure,  to  original  defect  of  the  lymph  ;  and  these  diff"er- 
ences  correspond  with  those  of  the  constitutional  states  attending  the 
two  diseases. 

After  the  discharge  of  the  pus,  the  healing  of  the  difiuse  suppuration 
is,  in  all  essential  respects,  similar  to  that  of  the  abscess ;  but  the 
methods  of  discharge  are  much  more  diverse.  Sometimes,  after  exten- 
sive sloughing  of  the  skin,  wide-spread  suppurating  cavities  are  exposed, 
which  then  granulate  and  heal  like  wide-open  wounds ;  sometimes  nu- 
merous isolated  suppurations  ensue,  whence  the  pus  is  discharged  as  from 
so  many  small  ill-defined  abscesses,  in  each  of  which  the  ordinary  heal- 
ing occurs,  while  the  intermediate  parts  are  indurated  by  the  imperfect 
organization  of  the  lymph ;  sometimes,  from  a  comparatively  small 
opening,  large  sloughs  are  discharged,  and  then  the  boundaries  of  the 
subcutaneous  cavities  which  they  leave  granulate,  and  healing  takes 
place  as  by  secondary  adhesion. 

The  superficial  inflammatory  suppuration  is  such  as  we  observe  in 
gonorrhoea,  and  in  purulent  ophthalmia,  and  generally  in  the  inflamma- 
tions of  mucous  membranes.  Here,  the  material  exuded  is  least  apt  for 
organization,  partly  because  of  the  situation  in  which  it  is  produced, 
and  partly  through  its  own  natural  condition ;  for  though  exudation 
takes  place,  in  these  cases,  within  the  tissue  of  the  inflamed  membrane, 
as  well  as  on  its  surface,  yet  the  amount  of  thickening,  or  other  struc- 
tural change,  that  takes  place  is  slight,  if  we  compare  it  with  the  changes 
that,  in  the  same  duration  and  severity  of  inflammation,  would  ensue 
in  connective  tissue,  or  in  serous  membranes. 

I  have  already  spoken  of  the  changes  of  mucus  in  the  inflammatory 
process,  and  of  the  mixture  of  lymph  that  then  occurs.  The  lymph  is 
mostly  of  the  corpuscular  kind.     It  is,  indeed,  chiefly,  in  some  of  these 


272  INFLAMMATORY   SUPPURATION. 

cases  of  inflamed  mucous  membranes,  that  one  may  doubt  whether  it  is 
reasonable  to  speak  of  the  formation  of  lymph-cells  as  preceding  that 
of  pus ;  for,  especially  in  the  more  acute  inflammations,  the  characters 
of  pus-cells  seem  to  be  acquired  in  the  very  beginning  of  organization 
of  the  exuded  liquid.  And  this  character  of  the  cells  is  often  retained, 
even  after  the  product  of  the  inflamed  membrane  has  regained,  to  the 
naked  eye,  a  more  mucous  appearance ;  for  here  (unless  ulceration  of 
the  membrane  have  ensued)  the  process  of  recovery  from  inflammatory 
suppuration  is  not  through  such  healing  by  granulation,  as  in  the  former 
cases,  but  by  a  gradual  return  to  the  secretion  of  a  more  normal  mate- 
rial; and  in  this  recovery,  the  inflammatory  exudation  becoming  gra- 
dually less,  the  corpuscles  that  are  formed,  though  they  may  assume 
the  characters  of  pus-cells,  are  not  sufficient  to  give  a  purulent  character 
to  the  liquid.* 

The  superficial  suppuration  from  inflamed  mucous  membranes  is 
closely  related  to  that  from  an  ulcerated  surface.  I  think,  indeed,  that 
an  inflamed  mucous  membrane  may  yield  purulent  matter,  even  though 
it  remain  covered  with  an  epithelium.  I  believe  this  happens  in  gonor- 
rhoea, and  in  purulent  ophthalmia ;  the  vascular  tissues  in  these  afi"ec- 
tions  appear  still  to  have  epithelium  on  them,  though  perhaps  it  is  too 
thin  and  immature,  and  is  reduced  to  a  condition  analogous  to  that  of 
the  thin  and  moist  glistening  epidermis  on  the  inflamed  "weeping"  leg. 
But  observations  are  wanting  on  this  point.  The  transition  to  the  sup- 
puration from  an  ulcerated  surface  takes  place  when  the  epithelium  is 
wholly  removed  from  a  mucous  membrane.  This  constitutes  its  abrasion 
or  excoriation ;  in  the  next  stage  the  surface  of  the  membrane  itself  is 
cast  off,  and  this  is  its  ulceration  or  erosion. f 

Such  are  the  several  chief  methods  of  inflammatory  suppuration,  and 
the  relations  of  the  pus  to  other  products  of  the  disease.  In  all  the  cases 
a  point  of  contrast  between  pus  and  any  form  of  lymph  is  to  be  found 
in  its  complete  incapacity  for  organization. 

*  The  question  of  the  diagnosis  between  mucus  and  pus  should,  perhaps,  be  here  re- 
ferred to.  Between  normal  mucus  and  pus  there  can  be  no  confusion.  Between  the  mucus 
and  the  pus  of  an  inflamed  mucous  membrane,  the  difference  corresponds,  in  some  measure, 
with  that  between  lymph  and  pus;  depending,  first,  on  the  proportion  in  which  the  in- 
flammatory material  is  mingled  with  the  proper  constituents  of  the  mucus,  and,  secondly, 
on  the  degree  in  which  the  former  tends  to  assume  the  purulent  characters.  In  other  words, 
the  diagnosis  required  is  not,  strictly  speaking,  so  much  between  mucus  and  pus,  as  between 
the  lymph  and  pus  which  are,  in  different  cases,  mingled  with  the  mucus  of  inflamed  mem- 
branes. And  this  diagnosis  is  one  which  it  is  easy  to  make,  in  many  cases,  according  to 
such  characters  of  the  corpuscles  as  have  been  already  described;  but,  in  other  cases,  it  is 
mpossible,  if  it  so  chance  that  the  materials  are  in  the  transition-stage  from  lymph  to  pus. 

t  The  thickness,  or  number  of  layers,  of  epithelium  normally  present  on  a  mucous  sur- 
face would  appear  to  exercise  an  important  influence  in  determining  whether  suppuration 
or  ulceration  should  take  place.  On  the  urinary  mucous  membrane,  for  example,  where  the 
epithelial  layers  are  several,  suppuration  is  the  rule:  whilst  on  the  intestinal  mucous  mem- 
brane, where  the  epithelial  layer  is  single,  ulceration  most  commonly  occurs. 


INFLAMMATORY    SUPPURATION.  273 

When  once  formed,  the  pus-cells,  if  they  are  retained  within  the  body, 
have  no  course  but  to  degenerate  further;  it  is  characteristic  of  their 
being  already  degenerate,  that  they  can  neither  increase  nor  develop 
themselves.  Various  corpuscles  found  in  pus,  besides  those  I  have 
already  mentioned,  may  find  their  interpretation  in  these  degenerations  ; 
for  the  pus-cells  are  prone  to  all  the  degenerations  that  I  described  as 
occurring  in  the  lymph-cells. 

They  may  wither,  as  in  the  scabbing  of  pustular  eruptions,  or  in  long- 
retained  and  half-dried  strumous  abscesses. 

Or,  they  may  be  broken  up,  whether  before  or  after  passing  into  the 
fatty  degeneration,  which  is  one  of  their  most  common  changes,  and  in 
which  they  are  transformed  into  granule-cells.  It  is  this  breaking 
up  into  minute  particles  which,  probably,  precedes  the  final  absorption 
of  pus. 

Or,  lastly,  both  the  cells  and  the  fiuid  part  of  the  pus  may  alike  yield 
fatty  and  calcareous  matter,  and  this  may  either  remain  diffused  in  fluid, 
or  may  dry  into  a  firm  mortar-like  substance. 

It  is  to  such  degenerations  as  these,  in  various  degrees  and  combina- 
tions, and  variously  modified  by  circumstances,  that  we  must  ascribe 
the  diverse  appearances  of  the  contents  of  chronic  abscesses,  and  of  the 
substances  that  remain  when  abscesses  close  without  complete  final  dis- 
charge of  their  contents.  In  such  abscesses  we  may  find  mixtures  of 
pus-cells,  granule-cells,  and  molecular  matter,  difi"used  in  more  or  less 
liquid :  or  pus-cells,  half-dried,  shrivelled,  and  showing  traces  of  their 
divided  nuclei ;  or,  all  the  cells  may  be  broken  up  and  their  debris  may 
be  found  mingled  with  minute  oily  particles,  which  appear  in  such  cases 
to  be  always  increasing ;  or,  with  these  may  be  abundant  crystals  of 
cholesterine  ;  or,  such  crystals  may  predominate  over  all  other  solid 
contents.  In  yet  other  chronic  abscesses  (though,  still,  without  our 
being  able  to  tell  why  the  pus  should  degenerate  in  these  rather  than  in 
the  foregoing  methods),  we  find  molecules  of  carbonate  and  phosphate 
of  lime,  mixed  with  fat  molecules  and  crystals,  which  are  difi"used  in  an 
opaque  white  fluid,  and  look  like  a  deposit  from  lime-water,  or  like  white 
oil-paint ;  and  as  these  contents  dry  in  the  healing  of  the  abscess,  so 
are  formed  the  mortar-like  deposits  and  the  hard  concretions  such  as 
are  found  in  the  substance  of  lymphatic  glands,  in  the  kidney,  or  other 
organs  that  have  been  the  seats  of  chronic  abscesses. 

Time  and  patience  would  fail  in  an  attempt  to  describe  all  the  varie- 
ties of  material  that  may  thus  issue  from  the  transformation  of  pus. 
What  I  have  enumerated  are  the  principal  or  typical  forms  with  which, 
I  believe,  nearly  all  others  may  be  classed  ;  though  not  without  consi- 
deration of  the  various  substances  that  may  be  accidentally  mixed  with 
the  pus  ;  as  blood,  debris  of  tissues,  &c. 

In  conclusion  of  this  part  of  the  subject, — of  this  biography  of  inflam- 
matory lymph, — a  few  words  must  be  added  respecting  the  degenera- 


274  DEGENERATIONS    AND    DISEASES 

tions  and  diseases  which  may  occur  after  it  is  completely  organized. 
The  degenerations  to  which  I  have  now  so  often  referred,  may  be  ob- 
served in  fully  formed  adhesions,  or  in  the  corresponding  organized 
tissues  in  the  substance  of  organs. 

Of  the  wasting  of  adhesions  we  often  see  instances  in  the  pericardium, 
where  films  of  false  membrane  are  attached  to  one  layer  of  the  mem- 
brane, while  the  opposed  portion  of  the  other  layer  is  only  thickened 
and  opaque.  A  more  remarkable  instance  is  presented  in  a  case  by 
Bichat,  in  which  a  man  made  twelve  or  fifteen  attempts  at  suicide,  at 
distant  periods,  by  stabbing  his  abdomen.  In  the  situations  of  the  more 
recent  wounds,  the  intestines  adhered  to  the  walls  of  the  abdomen ;  in 
those  of  the  older  wounds,  the  older  adhesions  were  reduced  to  narrow 
bands,  or  were  divided  and  hung  in  shreds. 

To  similar  wasting  atrophy  we  may  refer  the  extreme  thinning  and 
perforation  of  false  membranes,  by  which,  as  Virchow*  has  well  de- 
scribed, they  become  fenestrated  like  wasted  omentum.' 

Of  fatty  degeneration  I  have  seen  no  good  examples  in  adhesions  or 
similar  inflammatory  products,  but  of  calcareous  degenerations,  or  of 
such  as  present  a  combination  of  fatty  and  earthy  matter,  museums  pre- 
sent abundant  specimens.  Among  these  are  most  of  the  plates  of  bone- 
like substances  imbedded  in  adhesions  of  the  pleura,  in  thickened  and 
opaque  portions  of  the  cardiac  pericardium,  in  the  tunica  vaginalis,  in 
old  hydroceles,  in  the  thickened  and  nodulated  capsule  of  the  spleen,  in 
the  similarly  altered  mitral  and  aortic  valves.  So,  too,  many  of  the  so- 
called  ossifications  of  muscles  and  ligaments  are  examples  of  calcareous 
degeneration  of  fibrous  tissue,  formed  in  consequence  of  inflammation 
of  these  parts,  and  imbedded  in  masses  of  fibrous-looking  bands,  within 
their  substance.  In  some  of  these  cases,  indeed,  there  may  be  an 
approximation  to  the  characters  of  true  bone  (p.  85) ;  but  in  others  the 
earthy  matter  is  deposited  in  an  amorphous  form,  and  seems  to  take  the 
place  of  the  former  substance,  as  if,  according  to  Rokitansky,  it  were  a 
residue  of  the  transformation  of  the  more  organized  tissue,  whose  soluble 
pai'ts  have  been,  after  decomposition,  absorbed. f 

Pigmental  degeneration  of  adhesions  may  be  seen,  sometimes,  in 
those  of  the  pleura,  in  which  black  spots  appear  like  the  pigment- 
marks  of  the  lungs  and  bronchial  glands. |  Adhesions  of  the  iris,  also, 
may  become  quite  black,  by  the  formation  of  pigment  like  that  of  the 
uvea. 

Lastly,  it  must  be  counted  among  the  signs  of  its  attainment  of  com- 
plete membership  in  the  economy,  that  the  organized  product  of  inflam- 
mation is  liable  to  the  same  diseases  as  the  parts  among  which  it  is 
placed  ;  that  it  reacts  like  them  under  irritation ;   is,  like  them,  afi"ected 

*  Wurzburg  Verhandlungen,  B.  i,  p.  141. 

■f  Numerous  specimens  of  the  calcareous  degeneration  of  adhesions  are  in  the  College 
Museum;  e.g.  Nos.  103,  1493,  1494,  1516,  &c. 
J  As  in  No.  96  in  the  College  Museum. 


OF    ORGANIZED    LYMPH.  275 

by  morbid  materials  conveyed  to  it  in  the  blood ;  and,  like  them,  may 
be  the  seat  of  growth  of  new  and  morbid  organisms.  No  more  complete 
proof  of  correspondence  with  the  rest  of  the  body  could  be  afforded 
than  this  fact  presents ;  for  it  shows  that  a  morbid  material  in  the 
.blood,  minute  as  is  the  test  which  it  applies,  finds  in  the  product  of  in- 
flammation the  same  qualities  as  in  the  older  tissue  to  which  it  has 
peculiar  affinity. 

The  subject,  however,  of  the  diseases  to  which  these  substances, 
themselves  the  products  of  disease,  are  liable,  has  been  little  studied. 
I  can  only  enumerate  the  chief  of  them. 

Lymph,  while  it  is  being  highly  organized,  is  often  the  seat  of 
hemorrhage;  its  delicate  new-formed  vessels  bursting,  under  some  ex- 
ternal violence,  or  some  increased  interior  pressure,  and  shedding  blood. 
Such  are  most  of  the  instances  of  hemorrhagic  pericarditis,  and  other 
hemorrhages  into  inflamed  serous  sacs. 

Even  more  frequently,  the  lymph,  when  organized,  becomes  itself 
the  seat  of  fresh  inflammation.  Thus,  in  the  serous  membranes,  we 
may  find  adhesions,  in  the  substance  or  interstices  of  which  recent 
lymph  or  pus  is  deposited  ;*  or,  in  other  cases,  adhesions,  or  the 
thickenings  and  opacities  of  parts,  become  highly  vascular  and  swollen. 
It  is,  indeed,  very  probable  that,  in  many  of  the  instances  of  the  recur- 
ring inflammations  that  we  watch  in  joints,  or  bones,  or  other  parts,  the 
seat  of  the  disease  is,  after  the  first  attack,  as  much  in  the  organized 
product  of  the  former  disease  as  in  the  original  tissue. 

I  suppose,  also,  that  to  such  inflammations  of  organized  inflammatory 
products,  we  may  ascribe  many  of  the  occasional  aggravations  of 
chronic  inflammations  in  organs ;  the  renewed  pains  and  swellings  of 
anchylosed  joints,  of  syjphilitic  nodes,  and  the  like;  which  are  so  apt 
to  occur  on  exposure  to  cold  or  in  any  otherwise  trivial  disturbances  of 
the  economy.  In  such  cases  we  may  believe  that  the  former  seat  of 
disease  becomes  more  inflamed,  and  that  with  it  are  involved  the  or- 
ganized products  of  its  previous  inflammations.  And  in  such  cases 
there  are,  perhaps,  none  of  the  effects  of  inflammation  which  may  not 
ensue  in  the  newly  organized  parts  :  evidently,  they  may  be  softened, 
or  thickened  and  indurated,  and  made  more  firmly  adherent :  or  they 
may  be  involved  in  ulceration,  or  may  slough  with  the  older  tissues 
among  which  they  are  placed. 

Lastly,  the  products  of  inflammation  may  be  the  seats  of  the  morbid 
deposits  of  specific  diseases.  In  their  rudimental  state  they  may  in- 
corporate the  specific  virus  of  inoculable  diseases ;  such  as  primary 
syphilis,  variola,  and  the  rest,  and,  when  fully  organized,  they  may  be 
the  seat  of  cancer  and  tubercle. 

*  As  in  No.  1512  in  the  College  Museum.  The  specimen  has  some  historic  interest.  It 
is  one  of  those  by  which,  in  1808,  attention  was  first  drawn,  by  Sir  David  Dundas,  to  the 
connection  between  acute  rheumatism  and  disease  of  the  heart. 


276  SOFTENING  OF  INFLAMED  PARTS. 


LECTURE    XVII. 

CHANGES  PRODUCED  BY  INFLAMMATION  IN  THE  TISSUES  OP  THE 
AFFECTED  PART. 

The  account  of  the  results  of  inflammation  in  the  tissues  of  the  part 
in  which  it  has  its  seat,  will  include  the  chief  among  those  destruc- 
tive processes  which,  I  said  in  a  former  lecture  (p.  229),  may  be  reckoned 
as  a  second  division  in  the  inflammatory  changes  of  the  nutritive  pro- 
cess. For  I  believe  that  all  the  efi'ects  of  inflammation  are  injurious,  if 
not  destructive,  to  the  proper  tissues  of  the  part  in  which  it  is  seated. 
All  the  changes  I  shall  have  to  describe  are  characteristic  of  defect  of 
the  normal  nutrition  in  the  parts :  they  are  examples  either  of  local 
death,  or  of  some  of  the  varieties  of  degeneration,  modified  and  pecu- 
liarly accelerated  by  the  circumstances  in  which  they  occur.  The  dege- 
nerations are  observed  most  evidently,  in  the  processes  of  softening  and 
absorption  of  inflamed  parts.  These  I  shall,  first,  endeavor  to  illus- 
trate ;  and  then,  after  some  account  of  the  minute  changes  that  are 
associated  with  them,  I  will  describe  the  process  of  ulceration  :  reserving 
for  another  lecture  the  account  of  the  death  of  parts  that  may  occur  in 
inflammation. 

Let  me,  however,  at  once  state  that  the  changes  in  the  proper  tissues 
of  an  inflamed  part  are,  generally,  of  twofold  origin.  (1.)  They  are 
due  to  the  natural  degeneration  of  the  tissue.  That  degeneration, 
which  would  be  progressive  in  the  healthy  state,  but  which  would  then 
be  unobserved,  being  constantly  repaired,  is  still  progressive  in  the  in- 
flamed state  of  the  part,  and  is  the  more  rapid  because  of  the  suspen- 
sion or  impairment  of  the  proper  conditions  of  nutrition.  (2.)  They  are 
due,  also,  to  the  penetration  of  the  products  of  inflammation  into  the 
very  substance  of  the  afi"ected  tissue  ;  not  merely  into  the  interstices  of 
its  elemental  structures,  but  into  those  structures  themselves.  These 
two  methods  of  change  are  not  essentially  connected ;  but  they  are 
generally,  in  various  proportions,  coincident  and  mutually  influential ; 
and  when  concurring  it  is  hardly  possible  to  assign  to  each  its  share  in 
the  result  to  which  they  lead. 

One  of  the  most  common  efi'ects  of  inflammation  in  an  organ  is  a  more 
or  less  speedy  softening  of  its  substance  ;  and  this  is  due  not  only  to 
infiltration  of  it  with  fluid,  but  to  a  proper  loss  of  consistency,  a  change 
approaching  to  liquefaction,  or  to  disintegration,  of  which,  indeed,  it  is 
often  the  first  stage.  Of  such  softening,  some  of  the  best  examples  are 
in  the  true  inflammatory  softening  of  the  brain  and  spinal  cord,  in 
which  the  softened  part  is  usually  found  to  consist  of  broken  up  nervous 
substance,  together  with  more  or  less  abundant  granular  products  of 
inflammation.  Such  softening  also  may  be  found  in  the  lungs :  the  pe- 
culiar brittleness  and  rottenness  of  .texture,  which  exist  with  the  other 


SOFTENING-  OF  IXFLAMED  PAETS. 


277 


characters  of  hepatization,  are  evidently  due  to  changes  in  the  proper 
tissue,  more  than  to  incorporation  of  the  products  of  inflammation.  In 
staphyloma  of  the  cornea,  similar  softening  ensues  in  connection  with 
the  opacity  and  other  changes  of  appearance.  But,  perhaps,  the  most 
striking  instance  of  softening  in  inflammation  (and  it  is  the  more  so  be- 
cause the  softening  probably  precedes  the  other  evident  signs  of  inflam- 
mation*) is  to  be  found  in  bones.  One  may  generally  notice  that  an 
acutely  inflamed  bone  is  soft,  so  that  a  knife  will  easily  penetrate  it. 
Thus  it  may  be  found  in  the  phalanges  of  the  fingers  when  they  par- 
take in  deep-seated  inflammation,  and  thus,  sometimes,  in  the  neighbor- 
hood of  diseased  joints.  The  change  depends  partly  on  an  absorption 
of  the  earthy  matter  of  the  bone,  this  constituent  being  removed  more 
quickly,  and  in  greater  proportion,  than  the  animal  matter;  but  the 
entire  material  of  the  bone  is  softened. f 

The  softening  of  bones  may  permit  peculiar  subsequent  changes, 
especially  their  swelling  and  expansion.  Thus,  in  a  remarkable  case 
communicated  by  Mr.  Arnott  to  Mr.  Stanley,  after  excision  of  the 
bones  of  an  elbow  joint,  inflamma- 


tion ensued  in  the  shaft  of  the  hume- 
rus, and  after  four  months  the  pa- 
tient died.  The  end  of  the  humerus 
was  full-red,  and  swollen,  with  ex- 
pansion or  separation  of  the  layers 
of  its  walls  (Fig.  39).  And  the  case 
showed  well  the  coincidence  of  ab- 
sorption and  of  enlargement  by  ex- 
pansion ;  for  though  the  inflamed 
humerus  was  thus  enlarged,  and  con- 
tained more  blood  than  the  healthy 
one,  "  yet  it  was  found  not  to  weigh 
so  much  by  half." 

Similar  expansions  of  bone,  with 
all  the  characters  of  inflammation, 
and  such  as  could  not  have  hap- 
pened without  previous  softening 
of  the  tissues,  form  part  of  the 
many  swollen  and  enlarged  bones 


Fig.  394 


*  See  Kiiss,  as  quoted  by  Virchow,  in  his  Archiv,  i,  p.  121. 

f  In  inflammation  and  caries  of  bone,  in  addition  to  the  softening  caused  by  the  removal 
of  the  earthy  matter  there  is  also  a  considerable  widening  of  the  Haversian  canals,  lacuna;, 
and  canaliculi,  so  that  many  of  them  disappear,  owing  to  numerous  spaces  and  canals  being 
thrown  together.  See,  for  a  more  detailed  description  of  the  process,  Goodsir,  Anat.  and 
Path.  Obs.,  V.  Bibra,  Liebig  and  Wohler's  Annalen,  vol.  55;  Barwell,  Diseases  of  Joints. 

J  Fig.  39.  A,  the  inflamed  humerus.  The  swelling  of  its  lower  part  is  shown  by  con- 
trast with  that  of  the  corresponding  part  of  the  healthy  humerus,  B.  The  separation  of 
lamina"  is  shown  in  C  ;  all  the  figures  are  reduced  one-half.  From  Mr.  Stanley's  Illustra- 
tions, Pi.  i,  Figs.  4,  5,  6. 


278 


SOFTENING  OF  INFLAMED  PARTS. 


Fig.  40.f 


whicli  are  common  in  all  museums.*  Doubtless,  in  many  of  these  cases, 
the  disease  has  been  of  very  slow  progress,  and  the  separation  of  the 
several  layers  of  the  compact  bone,  which  the  specimens  display,  must 
be  ascribed  to  their  gradually  altered  form,  as  they  have  grown  about 
the  enlarging  bloodvessels  and  interlaminar  inflammatory  materials. 
But,  in  other  cases  the  expansion  has  in  all  probability  been  more  rapid, 
the  softened  bone  yielding  and  extending,  as  the  naturally  softer  tissues 
do,  in  an  inflammatory  swelling. 

The  characters  of  a  bone  thus  expanded  are  easily  discerned.  Its 
substance  may  be  irregularly  cancellous  or  porous ;  but  the  most  strik- 
ing change  is  a  more  or  less  extensive  and  wide  separation  of  the  con- 
centric laminae  of  the  walls  of  the  bone,  so  that,  as  in  the  section  of 
this  femur  (Fig.  40),  the  longitudinal  section  of  the  enlarged  wall  appears 
composed  of  two  or  more  layers  of  compact  tissue,  with  a  widely  can- 
cellous tissue  between  them :  and  these  layers  may  sometimes  be  traced 
into  continuity  with  those  forming  the  healthy  portion  of  the  wall. 
Usually,  the  separated  layers  are  carried  outwards,  and  the  bone  ap- 
pears outwardly  enlarged ;  but  sometimes  the  inner  layers  of  the  wall 
are  pressed  inwards  and  encroach  upon  the  medullary  tissue.  In  the 
first  periods  of  the  disease,  the  cancellous  tis- 
sue between  the  separated  layers  of  the  wall 
has  wide  spaces,  which  are  usually  filled  with  a 
blood-colored  medulla :  but  this  tissue,  like  the 
often  coincident  external  formations  of  new 
bone,  appears  to  have  a  tendency  to  become 
solid  and  hard ;  and  its  fibrils  and  laminse  may 
thicken  till  they  coalesce  into  a  compact  ivory- 
like substance,  harder  than  the  healthy  bone. 

Again,  for  examples  of  softening  in  inflam- 
mation, I  may  adduce  the  softening  of  liga- 
ments, such  as  permits  that  great  yielding  of 
them  which  we  almost  always  see  in  cases  of 
inflamed  joints.  This  is  not  from  mere  defec- 
tive nutrition ;  for  it  does  not  happen  in  the 
same  form,  or  time,  or  measure,  in  cases  of  pa- 
ralysis or  paraplegia  engendering  extreme 
emaciation,  l^either  is  it  from  the  soaking  of 
the  ligaments  with  the  fluid  products  of  the 
inflammation ;  for  it  does  not  happen  in  the 
abundant  effusions  of  the  slighter  inflammations 
of  the  joints;  and  when  ligaments  are  long  ma- 
cerated in  water  they  yet  retain  nearly  all  their 
inextensibility.  It  appears  to  be  a  peculiar 
softening,  or  diminished  cohesion  of  the  proper 

*  In  the  College  Museum,  Nos.  593  to  600,  and  3985  to  3094  ;   and  in  the  Mnseum  of 
St.  Bartholomew's,  Series  i,  Nos.  56,  94,  13S,  196,  197,  198.  &c. 

f  Fig.  40.     From  a  specimen  in  the  Museum  at  St.  Bartholomew's,  Series  i,  No.  94. 


INTEESTITIAL    ABSORPTION     OF    INFLAMED    PAETS.       279 

tissue  of  the  ligaments ;  the  result  of  a  degeneration  combined  with  in- 
filtration of  inflammatory  products. 

We  may  see  such  changes  in  the  ligaments  of  all  joints ;  in  the  hip, 
in  the  cases  of  spontaneous  dislocation  occasionally  seen,  independent 
of  suppuration  or  ulceration  of  the  parts  belonging  to  the  joint ;  in  the 
wrist,  when  the  ulna  after  disease  becomes  so  prominent ;  in  the  verte- 
brae, especially  in  the  ligaments  of  the  atlas  and  axis.  But  we  see  the 
eifects  of  this  softening  best  in  diseased  knee-joints  and  elbow-joints; 
and  in  all  these  cases  we  may  often  observe  an  interesting  later  change 
when  the  inflammation  passes  by.  The  ligaments,  softened  during  the 
inflammation,  yield  to  the  weight  of  the  limb,  or  more  rarely,  to  a  mus- 
cular force,  and  the  joint  is  distorted.  Then,  if  the  inflammation  sub- 
sides, and  the  normal  method  of  nutrition  in  the  joint  is  restored,  the 
elongated  ligaments  recover  their  toughness,  or  are  even  indurated  by 
the  organization  or  contraction  of  the  inflammatory  products  within 
them.  But  they  do  not  recover  their  due  position;  and  thus  the  joint 
is  stiffened  in  the  distortion  to  which  its  ligaments  had  yielded  in  the 
former  period  of  inflammation.  In  the  crowds  of  stiff",  distorted,  and 
yet  not  immovably  fixed,  joints,  that  one  sees  as  the  consequences  of 
inflammation,  these  changes  must  generally  have  happened  to  the  liga- 
ments :  first  softening  and  yielding ;  then  recovery,  with  induration, 
and  perhaps  some  contraction,  due  to  their  atrophy  and  the  organiza- 
tion of  the  inflammatory  material.  The  cases  are  aggravated  by  similar 
changes  in  the  adjacent  parts  ;  for  the  stiffhess  of  such  joints  is  not  due 
to  the  ligaments  alone;  all  the  subcutaneous  tissues  are  apt  to  be  adhe- 
rent and  indurated. 

The  absorption  of  the  affected  tissues  is  another  example  of  the 
destructive  changes  ensuing  in  the  inflammatory  process.  Like  the 
degenerations,  which,  probably,  always  precede  it,  it  is,  in  many  in- 
flammatory conditions,  a  peculiarly  rapid  event ;  and  it  may  affect,  at 
once,  the  proper  elements  of  a  part,  its  bloodvessels,  and  the  inflamma- 
tory products  that  may  have  been  previously  formed  among  them. 

I  shall  refer  here  only  to  that  which  has  been  called  interstitial  ab- 
sorption; to  the  removal  of  parts  from  within  the  very  substance  of  the 
tissues,  as  distinguished  from  the  removal  by  the  ejection  of  particles 
from  the  surface,  of  which  I  shall  afterwards  speak  as  occurring  in 
ulceration. 

Interstitial  absorption  of  inflamed  parts  is  seen  very  well  in  inflamed 
bones.  The  head  of  a  bone  may  be  scarcely  enlarged,  while  its  interior 
is  hollowed  out  by  an  abscess ;  what  remains  of  the  bone  may  be  in- 
durated, as  by  slight  and  tardy  inflammation,  but  so  much  of  the  bone 
as  was  where  now  the  abscess  is,  must  have  been  inflamed  and  absorbed. 
The  changes  are  well  shown  in  the  instance  of  abscess  in  the  lower  end 
of  the  tibia  which  is  here  drawn  (Fig.  41).*     Here,  too,  the  evidence  of 

*  Museum  of  St.  Bartholomew's,  Ser.  i,  No.  82. 


280       INTERSTITIAL    ABSORPTION    OF    INFLAMED    PARTS. 


absorption  is  completed  by  the  similar  excavations  formed  in  bones 
within  which  cysts  and  tumors  grow ;  for  in  these  cases  no  other  removal 
than  by  absorption  seems  possible. 

To  similar  absorption  of  inflamed  tissue  we  may  refer  the  wasting 
that  we  noticed  in  the  heads  of  bones  that  have  been  the  seat  of  chronic 
rheumatism.  The  best  examples  of  this  are  in  the  head  and  neck  of 
the  femur ;  and  the  retention  of  the  compact  layer  of  bone  covering  in 
the  wasted  cancellous  tissue  of  the  shortened  neck  and  flattened  head, 
is  characteristic  of  interstitial  absorption,  as  distinguished  from  ulcera- 
tion, by  which  the  cancellous  tissue  is  commonly  exposed.  In  these 
cases  of  chronic  inflammation  of  the  bones,  we  may  notice,  also,  an 
appearance  of  degeneration  that  precedes  a  peculiar  mode  of  absorption 


Fig.  41. 


Fig.  42. 


or  of  ulceration.  While  the  articular  cartilages  are  passing  through 
the  stages  of  fibrous  degeneration,  and  are  being  gradually  removed, 
the  subjacent  bone  is  assuming  the  peculiar  hardness  which  has  been 
termed  "  eburnation,"  or  "porcellaneous"  change.  ISTow,  this  change 
is  effected  by  the  formation  of  very  imperfect  bone ;  of  bone  that  has 
no  well-formed  corpuscles ;  and  it  resembles  the  result  of  mere  calcare- 
ous degeneration  rather  than  a  genuine  ossifying  induration.  And  its 
character  as  a  degeneration  is  further  declared  in  this  ;  that  it  is  prone 
to  destructive  perforating  ulceration,  which  often  gives  a  peculiar 
worm-eaten  appearance  to  the  bones  thus  diseased.* 


*  Hein  (Virchow's  Archiv,  B.  xiii.  p.  18,  1858)  states  that  the  worm-eaten  apertures  are 
occupied  in  the  recent  state  with  villous-like  processes  of  the  degenerate  fibro-cartilage.     A 


INTERSTITIAL    ABSORPTION    OF    INFLAMED    PARTS.       281 

With  these  changes  in  rheumatic  bones  we  may  also  cite,  as  instances 
of  absorption  during  slow  inflammation,  the  changes  Avhich  Mr.  Grulli- 
ver*  first  described  as  apt  to  ensue  after  injuries  about  the  trochanter 
of. the  femur  (Fig,  42).  In  such  cases,  without  any  appearance  of 
ulcerative  destruction,  the  head  and  neck  of  the  femur  may  waste  by 
absorption,  the  neck  becoming  shortened  and  the  head  assuming  a 
peculiar  conical  form.  We  might  regard  these  eifects  as  simple  atro- 
phy, if  it  were  not  that  they  are  like  the  effects  of  the  more  manifest 
inflammation  in  the  rheumatic  cases,  and  that  the  existence  of  inflam- 
mation during  life  is  often  declared  by  the  abiding  pain  and  other 
symptoms  following  the  injury. 

Again,  other  examples  of  the  absorption  of  inflamed  parts,  or  of 
parts  that  have  been  inflamed,  are  presented  in  the  wasting  of  glands 
after  inflammation ;  as  in  cirrhosis  of  the  liver,  in  some  forms  of  granu- 
lar degenerations  of  the  kidney,  in  the  indurated  and  contracted  lung 
after  pneumonia. 

No  doubt,  in  these  cases,  the  reduction  of  the  organ  depends,  in  a 
measure,  on  the  contraction  of  the  difi'used  inflammatory  product,  as  it 
organizes ;  but  in  many  cases  the  quantity  of  new  tissue  is  extremely 
small  (it  is  so  in  the  shrivelled  granular  kidney) ;  and,  in  all  the  cases, 
we  may  well  doubt  whether  the  contraction  of  organizing  lymph  would 
produce  such  extensive  and  uniform  absorption  of  the  proper  substance 
of  an  organ,  if  there  were  not  a  previous  condition  favoring  the  absorp- 
tion. The  most  probable  explanation  of  these  cases  seems  to  be,  that 
as,  in  the  early  periods  of  the  inflammation,  the  softening  and  the 
degeneration  of  the  inflamed  tissues  coincide  with  the  production  of  the 
lymph ;  so,  as  the  inflammation  subsides,  and  subsequently,  the  absorp- 
tion of  the  degenerated  tissues  may  often  coincide  w^ith  the  full  organi- 
zation and  contraction  of  the  lymph.  And  it  is  altogether  most  proba- 
ble that  these  events  are  independent  though  concurrent ;  and  that  each 
occurs  as  of  itself,  not  as  the  cause  or  consequence  of  the  others. 

To  all  these  cases  must  be  added  the  fact  of  the  absorption  of  the 
bloodvessels,  and  other  accessory  apparatus,  of  the  inflamed  tissues. 
The  absorption  of  the  absorbents  themselves  must  coincide  with  that  of 
the  tissues.  What  a  problem  is  here !  These,  that  had  once  been  the 
apparatus  maintaining  life,  that  had  been  adjusted  to  its  energy  and 
fashion,  now,  as  it  fails,  remove  themselves  in  adaptation  to  its  failure. 
How  can  this  be  ?  We  can  only  guess  that  its  method  is  just  the  reverse 
of  the  method  of  formation;  that,  as  in  growth  the  bloodvessels  and 

change,  which  appears  to  correspond  with  the  eburnation  of  bone,  is  described  by  JMr. 
Tomes,  as  occurring  in  a  part  of  a  tooth  which  lies  beneath  a  carious  cavity.  In  both  cases 
the  induration  might  suggest  that  it  is  calculated  to  retard  the  progress  of  the  disease,  but 
we  have  no  evidence  that  it  does  this  in  an  effective  manner ;  and  in  the  case  of  the 
bones  there  is  every  appearance  that  the  destruction  is  most  rapid  where  there  is  most 
induration. 

*  Edinburgh  Med.  and  Surg.  Journal,  vol.  46.  His  illustration  of  a  well-marked  case  is 
here  copied. — The  change  is  illustrated  in  No.  3312  in  the  College  Museum. 

19 


282  ABSORPTION    OF    INFLAMED     PARTS. 

lymphatics  follow  in  the  course  of  evolution  of  the  growing  parts,  open- 
ing and  extending  into  each  new  part  as  it  forms,  so,  in  decrease,  they 
follow,  and  closing  in  harmoniously  with  the  general  involution,  mingle 
their  degenerate  materials  with  those  of  the  tissue,  and  are  absorbed  by 
the  nearest  remaining  streams  of  blood. 

Once  more ;  not  only  the  original  elements  of  the  tissue  may  be 
absorbed,  but,  even  more  rapidly,  the  new-formed  products  of  inflamma- 
tion. We  have  the  best  examples  of  this,  as  well  as,  indeed,  of  many 
of  the  facts  which  I  have  been  mentioning,  in  the  spontaneous  opening 
of  a  common  abscess ;  which  though  it  be  so  common  a  thing,  I  will 
venture  to  describe  here. 

Let  us  suppose  the  case  of  an  abscess  formed  in  the  subcutaneous  tis- 
sue ;  of  such  a  one  as  I  described  some  pages  back,  and  may  illustrate 
by  this  sketch  of  an  imaginary  section  through  its  cavity  and  the  super- 
jacent skin  (Fig.  43).     It  has  had  its  origin  in  lymph  infiltrated  through 

'  Fig.  43. 


a  certain  area  of  the  tissues,  and  forming  therein  a  hard  circumscribed 
inflamed  mass.  Of  this  lymph  all  the  central  portion  is  suppurated, 
and  forms  the  purulent  contents  of  the  abscess ;  while  the  peripheral 
part  acquires  more  abundant  bloodvessels,  assumes  the  character  of  a 
granulation-layer  on  its  surface,  and  forms  the  proper  wall  of  the  ab- 
scess. 

The  pus  of  such  an  abscess  as  this  will  contain,  probably,  besides  its 
proper  constituents,  some  of  the  disentegrated  tissue  of  the  part  in 
which  it  has  its  seat.  We  cannot,  indeed,  be  quite  sure  of  this ;  for  it 
may  be,  that  while  the  lymph  is  being  formed,  or  being  converted  into 
pus,  the  proper  tissue  of  the  infiltrated  part  is  undergoing  absorption ; 
and  although,  in  the  pus  of  abscesses  thus  formed,  we  often  find  abun- 
dant molecular  and  granular  matter,  yet  this  may  be  the  ddbris,  not 
of  the  tissue,  but  of  the  cells  or  fibrine  of  the  inflammatory  product. 
We  cannot,  I  think,  be  sure  on  this  matter  ;  but  we  may  be  sure  that  one 
of  these  two  events  occurs ;  that  the  circumscribed  portion  of  tissue,  in 


OPENING    OF     ABSCESSES.  283 

which  such  an  abscess  has  its  seat,  degenerates ;  and  is  then  either 
absorbed,  or  else  disintegrated,  so  as  to  mingle  more  or  less  of  its  sub- 
stance with  the  pus. 

The  abscess  thus  formed  has  a  natural  tendency  to  open,  unless  all 
the  inflammation  in  which  it  had  its  origin  subsides.  Inflammation 
appears  to  be  not  only  conducive,  but  essential,  to  the  spontaneous 
opening  of  abscesses  ;  for,  where  it  is  absent,  the  matter  of  chronic 
abscesses  will  remain,  like  the  contents  of  any  cyst,  quiet  for  weeks,  or 
months,  or  years  ;  and  when  in  chronic  abscesses,  or  in  cysts,  inflamma- 
tion ensues  through  the  whole  thickness  of  their  coverings,  it  is  usually 
certain  that  their  opening  is  near  at  hand.  This  difference  between 
acute  and  chronic  abscesses  makes  it  very  doubtful  whether  the  in- 
flammation of  the  coverings  of  an  abscess  can  be  ascribed  to  any  local 
influence  of  the  pus.  But  to  whatever  it  may  be  ascribed,  we  may 
refer  to  this  inflammation,  and  to  the  degenerative  changes  that  accom- 
pany it,  the  comparatively  quick  absorption  of  the  integuments  and  of 
the  infiltrated  lymph,  over  the  collection  of  pus  :  and  thus  the  fact, 
however  we  may  account  for  it,  that  the  integuments  are  more  prone 
to  inflammation  and  more  actively  engaged  in  it,  than  the  other  tissues 
about  an  abscess  are,  may  be  used  to  explain  the  progress  of  matter 
towards  the  surface.  Possibly  (though  this,  I  think,  is  much  less  pro- 
bable) the  tissues  and  the  lymph  between  an  abscess  and  the  surface 
may,  after  the  degeneration  which  accompanies  the  inflammation,  be 
disintegrated,  and  may  mingle  their  molecules  with  the  purulent  con- 
tents of  the  abscess.  But,  in  favor  of  the  belief  that  they  are  absorbed, 
we  have  the  evidence  of  analogy  ;  for  just  the  same  thinning  and  re- 
moval of  integuments  takes  place  when  they  inflame  over  a  chronic 
abscess  with  a  thick  impenetrable  cyst,  or  over  an  encysted  or  even  a 
solid  tumor.  In  these  cases,  absorption  alone  is  possible ;  and  the 
cases  are  so  similar  to  the  ordinary  progress  of  abscesses,  that  I  think 
we  may  assign  all  the  changes  of  the  integuments  over  these  to  the 
same  interstitial  absorption. 

During,  or  preparatory  to  their  absorption,  the  integuments  over  an 
abscess  become  softer  and  more  yielding.  The  change  is,  most  pro- 
bably, due  to  such  softening  as  I  have  described  in  degenerating  in- 
flamed parts.  It  takes  place  especially  in  the  portion  of  the  integu- 
ments over  the  middle,  or  over  the  most  dependent  part,  of  the  abscess  ; 
and  this  most  softened  portion,  yielding  most  to  the  pressure  of  the 
pus,  becomes  prominent  beyond  the  parts  around  it,  and  points.  Mr. 
Hunter  refers  to  this  as  "  the  relaxing  or  elongating  process."  He 
says  :  "  Besides  these  two  modes  of  removing  whole  parts,  acting  singly 
or  together  [that  is,  besides  the  interstitial  and  the  progressive  absorp- 
tion], there  is  an  operation  totally  distinct  from  either,  and  this  is  a 
relaxing  and  elongating  process  carried  on  between  the  abscess  and  the 
skin,  and  at  those  parts  only  where  the  matter  begins  to  point.  It  is 
possible  that  this  relaxing,  elongating,  or  weakening  process,  may  arise 


284  ABSORPTION    OF    INFLAMED    PARTS. 

in  some  degree  from  the  absorption  of  the  interior  parts ;  but  there  is 
certainly  something  more,  for  the  skin  that  covers  an  abscess  is  always 
looser  than  a  part  that  gives  way  from  mere  mechanical  distension,  ex- 
cepting the  increase  of  the  abscess  is  very  rapid. 

"  That  parts  relax  or  elongate  without  mechanical  force,  but  from 
particular  stimuli,  is  evident  in  the  female  parts  of  generation,  before 
the  birth  of  the  foetus ;  they  become  relaxed  prior  to  any  pressure. 
The  old  women  in  the  country  can  tell  when  a  hen  is  going  to  lay  from 
the  parts  becoming  loose  about  the  anus."* 

While  these  changes  of  degeneration,  leading  to  softening  and  ab- 
sorption, are  ensuing  in  the  cutis  and  the  lymph  over  such  an  abscess 
as  I  have  described,  we  commonly  notice  that  the  cuticle  separates, 
leaving  the  very  point,  or  most  prominent  part,  of  the  abscess  bare 
(Fig.  43).  The  cuticle  is  sometimes  raised  as  in  a  blister ;  but  much 
more  often  it  cracks  and  separates,  and  then,  with  its  broken  edges 
raised,  peels  off  like  dead  cuticle :  and  we  may  believe  that  it  is  dead, 
partaking  of  the  failure  of  nutrition  in  which  all  the  parts  over  the 
abscess  are  involved,  and  being  removed  as  a  dead,  not  as  a  merely  de- 
generated, part. 

At  length,  after  extreme  thinning  of  the  integuments,  they  perish  in 
the  centre  of  the  most  prominent  part.  Sometimes  the  perished  part 
becomes  dry  and  parchment-like,  with  a  kind  of  dry  gangrene ;  but 
much  more  commonly  a  very  small  ordinary  slough  is  formed,  and  the 
detachment  of  this  gives  issue  to  the  purulent  matter.  The  discharge 
is  usually  followed  by  a  more  or  less  complete  cessation  of  the  inflamma- 
tion in  the  integuments,  and  then  the  wall  of  the  abscess,  having  the 
character  of  a  cavity  lined  with  healthy  granulation,  heals. 

The  softening  and  absorption  of  inflamed  tissues  of  which  I  have 
been  speaking,  are  the  chief  consequences,  or  attendants,  of  minuter 
molecular  changes,  to  which  I  must  now  refer.  These  changes  are  de- 
rived, as  I  have  already  said,  from  one  or  both  of  two  sources  ;  namely, 
the  natural  degenerations  of  the  inflamed  tissues,  and  their  penetration 
by  the  inflammatory  product. 

The  rapid  softening  of  an  inflamed  tissue  is,  probably,  in  most  cases, 
dependent  on  both  these  conditions ;  and  yet  in  some  cases,  and  in 
some  measure  in  all,  it  may  be  ascribed  to  a  simple  degeneration,  such 
as  might  be  classed  with  those  named  liquefactive.  Thus,  in  the  case 
of  the  integuments  over  an  abscess,  we  find  it  associated  with  infiltra- 
tion of  degenerating  lymph-products,  and  probably  in  some  measure 
due  to  their  presence :  but  in  the  brain  and  spinal  cord,  the  softenings 
of  inflammation  are,  in  structure,  and  probably  also  in  nature,  very  like 
those  of  mere  atrophy. 

*  On  the  Blood,  &c.  "Works,  vol.  iii,  p.  477.  The  last  fact  is,  probably,  not  appropri- 
ately cited.  The  change  in  the  state  of  parts  before  the  birth  is  most  likely  due  to  relaxa- 
tion of  the  abundant  muscular  fibres  that  they  all  contain. 


DEGENERATION'S    OF    INFLAMED    TISSUES.  285 

Less  rapid  softening  is  often  connected  with  a  well-marked  fatty  de- 
generation of  the  inflamed  tissues.  This  is  especially  the  case  in  the 
muscles,  bones,  cartilages,  cornea,  and  certain  glands,  as  the  liver  and 
kidney. 

I  found  such  a  degeneration  well  marked  in  the  fibres  of  the  heart  of 
a  man,  who  thrust  a  needle  through  his  left  ventricle  four  days  before 
his  death.  There  were  evident  signs  of  pericarditis,  and  of  inflamma- 
tion of  the  portion  of  the  heart  close  by  the  wound;  and  both  in  this 
portion,  and,  in  a  less  degree,  in  all  other  parts  of  the  heart,  I  found 
such  a  fatty  degeneration  of  the  muscular  fibres  as  I  could  not  have 
distinguished  from  that  which  occurs  in  the  corresponding  atrophous 
degeneration.  The  same  changes  may  be  oftener  observed  at  later 
periods  after  inflammation  of  the  substance  of  the  heart ;  and  in  some 
of  these  cases  the  interstitial  deposits  of  lymph  are  organized  into 
fibrous  tissue,  while  the  muscular  fibres  themselves  are  degenerate. 
The  extended  observations  of  Virchow,  on  the  inflammations  of  mus- 
cles,* show  that  such  fatty  degeneration  of  the  fibres  usually  occurs  in 
nearly  all  but  the  most  acute  cases  ;  in  these,  softening  and  disintegra- 
tion of  the  muscular  fibrils  rapidly  ensue,  and  fatty  particles  appear 
subsequently,  if  at  all,  in  the  inflammatory  exudation  and  disintegrated 
tissue  that  are  mingled  with  the  sarcolemma.  He  shows,  also,  very 
clearly,  how  the  changes  in  the  muscular  fibres  may  be  associated  with 
the  eff"ects  of  lymph  produced  interstitially  among  them,  as  well  as 
within  them,  and  passing  through  its  ordinary  progress  of  development 
or  degeneration ;  and  that  they  may  be  followed  by  the  complete  wast- 
ing, or  absorption,  of  the  degenerate  tissue,  in  the  place  of  which  the 
new  fibrous  tissue  formed  by  the  developed  lymph  may  remain  like  a 
scar  or  a  tendinous  spot. 

In  inflamed  bone,  also,  Virchow  has  traced  fatty  degeneration  as  a 
part  of  the  process  of  softening  which  precedes  its  expansion  or  absorp- 
tion. The  change  is  observed  not  constantly,  yet  very  often,  as  a  fatty 
degeneration  of  the  bone-corpuscles,  in  the  interior  of  which  small  fatty 
molecules  appear.  After,  or  sometimes  without,  such  previous  changes 
in  the  corpuscles,  he  has  also  traced  their  enlargement  and  the  gradual 
softening,  disintegration,  and  final  liquefaction  and  separation  of  the 
proper  bone-substance,  immediately  surrounding  and  including  each  cor- 
puscle. The  changes  he  has  thus  traced  accord  completely  with  those 
described  by  Goodsirf  and  Redfern|  in  the  cartilage ;  and  as  he  well 
observes,  they  have  peculiar  interest  in  relation  to  the  occurrence  of 
degeneration,  as  a  part  of  the  inflammatory  process,  inasmuch  as  they 
are  the  results  of  the  same  process  as  that  by  which,  normally,  the 
medullary  spaces  and  areolae  of  growing  bone  are  formed,  by  which,  as 

*  In  his  essay  on  Parenchymatous  Inflammation,  Archiv,  B.  iv,  h.  i,  p.  266. 
f  Anatomical  and  Pathological  Observations,  1845. 

J  Anormal  Nutrition  in  Articular  cartilages:  Edinburgh,  1850.  And  "On  the  Healing 
of  Wounds  in  Articular  Cartilages,''  in  the  Monthly  Journal  of  Medical  Science,  Sept.,  1851. 


286  DEGENERATIONS     OP     INFLAMED     PARTS. 

the  bone  grows,  the  compact  cortical  tissue  is  gradually  changed  into 
areolar  or  spongy  tissue,  and  by  which  the  peculiar  "mollities  ossium," 
or  "osteomalacia,"  is  produced. 

Changes  like  these  in  inflamed  bone  have  been  found  in  ulcerating 
and  articular  cartilage  ;  and  they  are  here  the  more  important,  as  show- 
ing the  process  essentially  similar  to  the  degeneration  of  inflammation, 
although  occurring  in  a  tissue  that  has  no  bloodvessels,  and  into  which 
we  have  no  evidence  of  the  penetration  of  lymph.  They  have  been 
chiefly  observed  by  Goodsir  and  Redfern  ;  but  have  been  confirmed  by 
many.*  They  consist  essentially  in  the  enlargement  of  the  cartilage- 
cells,  with  increase  of  the  nuclei,  or  of  peculiar  corpuscles  contained  in 
them,  or  with  fatty  degeneration  of  their  contents,  and  fading,  or  similar 
degeneration  of  their  nuclei.  The  hyaline  intercellular  substance  at  the 
same  time  splits  up,  and  softens  into  a  gelatinous  and  finely  molecular 
and  dotted  substance,  or  else  is  gradually  transformed,  in  the  less  acute 
cases,  into  a  more  or  less  fibrous  tissue.  The  enlarged  cartilage-cells 
on  the  surface  are  released,  and  may  discharge  their  contents  on  the 
surface  of  the  ulcer ;  and  the  intercellular  substance  is  gradually  dis- 
integrated and  similarly  discharged,  or,  whatever  part  of  it  remains,  is 
transformed  into  fibrous  tissue,  and  becomes  the  scar  by  which  the 
ulceration  is,  in  a  measure,  healed. 

Lastly,  in  the  cornea,  a  series  of  observations  on  the  effects  of  in- 
flammation, purposely  excited  in  it  by  various  stimuli,t  have  shown  that 
the  changes  in  it  are  not  due  to  any  free  exudation  of  lymph  in  it,  but 
to  alteration  in  its  proper  constituent  textures.  They  consist,  chiefly, 
in  swelling  and  enlargement  of  its  corpuscles,  the  appearance  of  minute 
fatty  molecules  in  them,  and  the  increase  and  enlargement  of  their 
nuclei.  The  intercellular  substance  becomes,  at  the  same  time,  turbid, 
more  opaque,  denser,  more  fibrous,  and,  sometimes,  finely  granulated  ; 
and  in  some  cases,  fatty  molecules  appear  in  it.  The  changes  thus  pro- 
duced in  the  cornea  are  not  essentially  difi'erent  from  those  that  follow 
its  idiopathic  inflammations ;  and,  as  Virchow  concludes,  they  are  ex- 
tremely like  those  of  the  arcus  senilis. 

Now,  from  all  these  cases,  with  which  others  of  similar  import  might 
be  combined,  we  may  conclude  that  the  degeneration  of  the  proper  tis- 
sues of  inflamed  parts,  which  we  recognize  in  the  mass  as  a  softening 
of  their  substance,  or  an  aptness  to  be  absorbed,  is,  very  often,  essen-. 

*  Reference  may  be  especially  made  to  a  paper  by  C.  0.  Weber,  in  Virchow's  Archiv, 
B.  xiii,  ]  858,  and  to  Barwell's  Treatise  on  Diseases  of  Joints,  1861.  The  former  author  de- 
scribes new  vessels  as  extending,  not  only  over  the  surface  of  the  ulcerating  cartilage,  but 
aftervs^ards  penetrating  its  substance. 

f  They  are  published  briefly  in  Virchow's  essay  already  cited ;  and  in  detail  in  a  disser- 
tation— "  Der  normale  Bau  der  Cornea  und  die  patbologischen  Abweichungen  in  demselben," 
Wiirzburg,  1851 — by  Fr.  Strube,  by  whom  the  observations  were  made  under  the  superin- 
tendence of  Virchow.  Additional  and  more  extended  observations  have  been  made  by  His 
in  the  Wiirzburg  Verhandl.  vol.  iv,  and  in  Virchow's  Archiv,  vol.  vi,  and  by  Rindfleisch 
in  the  Archiv,  vol.  xvii,  1859. 


DEGENERATIONS     OF    INFLAMED     PARTS.  287 

tially  like  the  fatty  degeneration  which  we  have  studied  as  a  form  of 
atrophy  of  the  same  parts  ;  that  the  changes  of  structure  are,  in  both, 
essentially  the  same  ;  differing  in  rate  of  progress,  but  not  in  method  or 
result.  And  the  cases  of  the  bones,  cartilages,  and  cornea,  are  the 
more  to  be  considered,  because  the  changes  described  in  them  cannot 
be  referred,  in  any  considerable  measure,  if  at  all,  to  a  process  of  exu- 
dation into  the  elements  of  their  tissues. 

The  fatty  degeneration  and  that  of  softening,  as  by  progressive 
liquefaction,  are,  doubtless,  the  most  general  forms  in  which  the  defec- 
tive nutrition  in  an  inflamed  part  is  manifested.  But  something  allied 
to  the  calcareous  degeneration  occurs  in  the  ossifications  of  the  laryn- 
geal cartilages  when  they  are  involved  in  inflammation,  and  of  such 
other  cartilages  as  are  prone  to  an  imperfect  ossification  in  old  age. 
These  are  frequent  events ;  and  as  Virchow  observes,  the  ossification 
occurs  constantly  and  often  exclusively  in  -  the  very  part  of  the  carti- 
lages which  corresponds  with  the  seat  of  the  inflammation.  To  the  same 
class  of  cases  we  may  refer  the  ossifications  of  parts  of  the  articular 
cartilages  in  chronic  rheumatic  arthritis  and  the  formation  of  the  im- 
perfect dentine  or  osteo-dentine  which  ensues  in  inflammatory  affections 
of  the  tooth-pulp,  or  in  the  pulp  of  the  elephant's  tusk  around  bullets 
lodged  in  it.  In  all  these  cases  it  may  be  observed,  the  inflammatory 
process  is  attended  with  such  changes  as  occur  almost  normally  at  some 
later  period  of  life,  or  in  old  age  ;  such  changes,  then  occurring,  are 
reckoned  among  the  natural  degenerations,  the  signs  of  simply  defec- 
tive formative  power :  the  difference,  therefore,  between  the  natural 
degeneration  and  that  of  the  inflammatory  process  seems  to  be  one  of 
time  more  than  of  kind ;  the  inflammatory  is  premature  and  compara- 
tively rapid,  and  ensues  with  the  characters  of  disturbed,  rather  than  of 
merely  defective,  nutrition. 

Such  are  some  of  the  evidences  of  degeneration  ensuing  in  the  proper 
tissues  of  inflamed  parts.  The  cases  I  have  selected  are  of  the  simplest 
kind ;  whose  results  are  least  confused  by  the  changes  that  may  ensue 
in  lymph  penetrating  the  degenerating  tissue.  When  this  happens,  it 
is  perhaps  impossible,  at  present,  to  separate  the  two  series  of  changes ; 
those,  I  mean,  which  are  due  to  the  degeneration  of  the  elements  of  the 
tissue,  and  those  which  are  occurring  in  the  lymph  within  them.  The 
latter  are  especially  described  by  Virchow  in  the  muscular  fibres,  and 
in  the  renal  cells,  in  what  he  calls  the  parenchymatous  form  of  granu- 
lar degeneration  of  the  kidney.  In  the  latter  he  says*  that  while,  as  in 
the  croupous  form,  fibrinous  cylinders  of  free  inflammatory  exudation 
may  be  found  in  the  straight,  and  a  part  of  the  convoluted  tubes,  other 
changes  are  ensuing  in  the  epithelial  cells ;  and  by  these  chiefly,  and 
sometimes  alone,  the  characteristic  altered  structure  of  the  kidney  is 

*  In  his  essay,  referred  to  at  p.  320.  Many  of  his  facts  were  published  by  one  of  his 
pupils,  Dr.  Neimann,  in  his  dissertation,  "  De  inflammatione  renum  parenchymatosa,  Berol. 
1848." 


288  ULCERATION. 

induced.  Tliey  occur  especially  in  those  parts  of  the  tubes  which  run 
transversely  or  obliquely.  In  the  first  stage  of  the  disease  these  cells 
enlarge,  and  their  molecular  nitrogenous  contents  increase,  by  the  pene- 
tration of  the  inflammatory  product  into  them.  In  the  second  stage, 
the  increase  is  such  that  the  cells  break  up,  and  the  urine-tubes  appear 
filled  with  a  molecular  albuminous  substance  ;  or  else  the  fatty  transfor- 
mation ensues  in  them,  and  they  are  filled  with  finely  granular  fatty 
matter,  and  appear  as  granule-cells  or  granule-masses.  In  the  third 
stage  the  fat-granules  dispart,  and  an  emulsive  fluid  is  formed,  which 
may  be  absorbed  or  discharged  with  the  urine. 

Virchow  describes  similar  changes  in  the  hepatic  cells :  but  it  may 
suflBce  only  to  refer  to  these.  What  has  been  already  described  will  be 
enough,  I  hope,  to  justify  the  expressions  used  at  the  beginning  of  the 
lecture :  namely,  that  the  changes  (short  of  death)  which  ensue  in  the 
proper  elements  of  an  inflamed  part  are  twofold  :  first,  those  of  a  de- 
generation, such  as  might  ensue  in  simply  defective  or  suspended  nutri- 
tion ;  and.  secondly,  those  which  depend  on  the  penetration  of  the  exuded 
inflammatory  product.  Either  of  these  may,  perhaps,  occur  alone,  but 
the  first  can  be  rarely,  if  ever,  absent.  When  they  are  concurrent, 
their  several  efi"ects  cannot  be  clearly  separated  ;  and  when  they  both 
take  place  rapidly,  the  degeneration  is  apt  to  lose  all  likeness  to  such 
as  naturally  occur,  and  to  appear  as  only  contributing  to  the  rapid  dis- 
integration and  liquefaction  of  both  the  tissue  and  the  inflammatory 
product.  This  appears  to  be  the  case  in  many  instances  of  ulceration ; 
a  process  which  I  have  deferred  to  the  very  end  of  the  history  of  in- 
flammation, because  all  the  other  parts  of  the  disease  appear  to  be  en- 
gaged in  it. 

I  need  hardly  say,  that,  ever  since  Hunter's  time,  confusion  has 
existed  in  the  use  of  the  terms  employed  for  various  kinds  or  methods 
of  absorption  and  ulceration.  Of  all  that  Hunter  wrote,  nothing,  I 
think  is  so  intricate,  so  difiicult,  to  understand,  as  his  chapter  on  ulcer- 
ative inflammation  ;  and  much  of  the  obscurity  in  which  he  left  the  sub- 
ject remains.  Some  of  this  depends  on  the  same  terms  having  been 
used  in  different  senses,  and  may  be  avoided  if  it  is  agreed  to  speak  of 
the  removal  of  those  particles  of  inflamed  parts,  which  are  not  on  an 
open  or  exposed  surface,  as  the  "  interstitial  absorption"  of  inflamed 
parts.  Then,  the  term  "  ulceration"  may  be  employed  to  express  the 
removal  of  the  superficial  or  exposed  particles  of  inflamed  parts :  or, 
rather,  Avhen  the  epithelium  or  epidermis  of  an  inflamed  part  is  alone 
removed,  it  may  be  called  "  abrasion"  or  "  excoriation  ;"  and  when  any 
of  the  vascular  or  proper  tissue  is  removed  from  the  surface,  it  may  be 
called  "ulceration,"  If,  in  such  ulceration,  the  superficial  particles 
may  be  supposed  to  be  absorbed,  the  process  of  removing  them  may  be 
termed  "  ulcerative  absorption  ;"  but  if,  as  is  more  probable,  their  re- 
moval is  effected  entirely  by  ejecting  them  from  the  surface  of  the  in- 


ULCERATIOiSr.  289 

flamed  part,  tlien  the  term  "  ulceration"  may  sufficiently  express  this 
ejection,  and  will  stand  in  stronger  contrast  to  the  "interstitial  ab- 
sorption" of  the  particles  that  are  not  so  ejected,  but  are  taken  into 
the  blood. 

I  have  lately  referred  to  the  uncertainty  whether,  as  the  cavity  of  an 
abscess  enlarges  or  opens,  the  tissues,  and  the  infiltrated  lymph,  that 
are  removed  from  the  inner  surface  of  its  boundary  walls,  are  absorbed, 
or  are  disintegrated  and  mingled  with  its  fluid  contents  :  in  other  words, 
whether  they  are  absorbed  or  rejected.  The  same  uncertainty  exists, 
in  some  measure,  in  the  case  of  ulceration,  concerning  which,  indeed, 
all  that  was  said  respecting  the  necessity  of  inflammation  to  the  open- 
ing of  abscesses,  might  be  'here  repeated,  inasmuch  as  inflammation 
seems  essential,  not  only  to  the  formation,  but  to  the  extension  or  en- 
largement, of  an  ulcer.  The  ulcerative  process  cannot  take  place  in 
healthy  tissue ;  previous  degeneration  of  the  tissue,  and  that  such  as 
occurs  in  the  inflammatory  process,  is  a  condition  essential  to  it. 

But  when  this  condition  is  provided,  is  the  enlargement  of  an  ulcer 
efi'ected  by  absorption  of  its  boundaries,  or  by  the  gradual  detachment 
and  casting  ofi"  of  particles  from  their  free  surface  ?  Both  methods  of 
enlargement  may,  perhaps,  in  some  cases,  ensue ;  but  the  probabilities 
are  in  favor  of  the  enlargement  being,  as  a  general  rule,  efi'ected  by  the 
ejection  of  particles. 

Thus  :  1.  Parts  to  be  removed  from  a  surface  are  generally  cast  ofi" 
rather  than  absorbed,  as  cuticles  of  all  kinds  are,  and.  the  materials  of 
secretions  ;  so  that,  by  analogy,  we  might  assume  that  the  particles  of 
the  surface  of  a  spreading  ulcer  would  also  be  cast  ofi". 

2.  The  materials  of  the  ulcerating  tissue  may  be  sometimes  found  in 
the  discharge  from  the  ulcer.  In  most  cases,  indeed,  this  is  impossible ; 
but  perhaps  it  is  so  only  because,  when  the  tissues,  and  the  lymph  pro- 
duced in  them,  are  degenerate  and  broken  up,  or  decomposed  and  dis- 
solved, we  have  no  tests  by  which  to  recognize  them.  In  the  ulcera- 
tion of  cartilage,  however,  in  which  inflammatory  exudation  has  no 
share,  the  process  of  ejection  of  the  disintegrated  tissue  is  clearly 
traced ;  and  we  might  deem  this  almost  a  proof  of  the  same  process 
being  observed  in  other  tissues,  if  it  were  not  that  in  the  cartilage  a 
necessary  condition  of  absorption,  th^  presence  of  a  circulation,  is 
wanting.  The  same  process  of  ejection,  however,  is  traceable,  in  ulcer- 
ating bone,  where  absorption  might  occur.  It  is  shown  by  the  observa- 
tions which  I  have  quoted  from  Virchow ;  and  Mr.  Bransby  Cooper 
has  observed  that,  while  in  pus  from  soft  parts  only  traces  of  phosphate 
of  lime  are  found,  the  pus  from  around  diseased  bone  contains  in  solu- 
tion nearly  2^  per  cent.*  A  similar  but  less  complete  observation  had 
been  made  by  Mr.   Thomas  Taylor,f  and  by  v.  Bibra  ;|  and  we  may 

*  Medical  Gazette,  May,  1845. 

J  Stanley  :  Treatise  on  Diseases  of  the  Bones,  p.  89. 

J  Chemische  Untersuchungen  versehiedener  Eiterarten,  p.  85. 


290  ULCERATION. 

believe  that  at  least  some  of  the  phosphate  of  lime  in  these  cases  was 
derived  from  the  diseased  bone.* 

3.  It  strengthens  this  belief  to  observe  that,  in  many  cases,  small 
fragments  of  bone  and  other  tissues  are  detached,  and  cast  out  with  the 
fluid  from  the  ulcerating  part.  These,  indeed,  when  they  are  not  frag- 
ments of  tissue  detached  by  ulceration  extending  around  them,  are 
good  examples  of  the  transition  that  may  be  traced  from  ulceration  to 
sloughing  or  gangrene  of  parts,  between  which,  if  ulceration  be  always 
accomplished  by  ejection,  the  only  essential  difference  will  be  one  of 
degree ;  the  ulceration  being  a  death  and  casting  off  of  invisible  par- 
ticles of  a  tissue,  while  gangrene  implies  the  death  and  casting  off  of 
visible  portions. 

4.  And  it  may  be  proved  of  many  that  we  call  ulcers,  that  they  begin 
as  sloughs,  which  are  cast  off,  and  leave  the  ulcerated  surface  beneath. 
We  may  often  see  this,  on  a  large  scale,  in  the  instances  of  what  are 
called  sloughing  ulcers ;  but  Dr.  Baly  has  proved  it  for  a  much  wider 
range  of  cases,  in  his  observations  on  dysentery,  in  which  he  has  traced 
how  even  the  smallest  and  the  most  superficial  ulcers  of  the  intestine 
are  preceded  by  the  death  and  detachment  of  portions  of  the  mucous 
membrane,  Avith  its  epithelial  investment. f 

From  these  considerations  we  may  hold  it  as  probable  that  ulceration 
is,  usually,  the  result  of  the  detachment  of  dead  portions  or  molecules 
of  an  inflamed  tissue,  and  that  the  substance  removed  in  the  process  is 
not  absorbed  but  ejected.  There  are,  indeed,  some  cases  which  may 
make  us  willing  to  admit,  at  present,  that  all  ulceration  is  by  ejection ; 
such  as  those  of  bone  ulcerating  under  cartilage,  or  in  the  rapid  exten- 
sion of  inflammation  within  it,  or  such  as  the  spreading  ulceration  of 
the  vertebrae,  or  of  the  heads  of  bones,  that  is  not  attended  with  ex- 
ternal discharge  of  fluid.  These  may,  for  the  present,  interfere  with 
the  universality  of  the  rule,  but  not  with  its  generality. 

But,  if  we  may  believe  that  the  removal  of  a  tissue  by  ulceration  is 
generally  effected  by  ejection  of  its  substance,  the  question  may  be 
asked,  in  what  form  is  it  ejected?  Dr.  Baly's  observations  enable  us 
to  say  that,  in  the  first  instance,  a  visible  slough  is  detached,  a  portion 
of  the  tissue  dying  and  being  disconnected  from  the  adjacent  living 

*  The  belief  may  seem  the  more  reasonable,  because  of  the  similar  fact  of  the  quick  ab- 
sorption of  bone-earths  in  inflamed  but  not  ulcerating  bones.  Still,  it  must  be  admitted, 
more  evidence  is  needed  that  the  quantity  of  bone-earths  discharged  with  the  pus  is  pro- 
portionate or  equal  to  the  quantity  lost  by  the  ulcerating  bone.  For  if  what  has  been  said  of 
the  conformity  of  the  properties  of  inflammatory  and  reparative  products  with  those  of  the 
tissues  from  which  they  are  produced,  be  true,  then  will  also  pus  from  diseased  bone  possess 
more  bone-earths  than  pus  from  any  other  tissue,  even  though  the  bone  be  not  ulcerating. 
Granulations  upon  bone  doubtless  contain  more  bone-earths  than  those  on  soft  parts,  and  they 
may  ossify  :  now  the  relation  of  pus  to  granulations  is  commonly  that  of  degenerating  cells 
to  the  like  cells  developing ;  therefore  we  might  expect  that  pus  from  bone,  like  granulations 
from  bone,  will  contain  a  large  proportion  of  bone-earths,  independent  of  what  may  be  derived 
from  the  ulceration  of  the  bone. 

f  Gulstonian  Lectures :  Medical  Gazette,  1841 . 


ULCERATION.  291 

tissue.  But,  after  this  is  done,  when  an  ulcer  enlarges,  or  extends  and 
spreads,  is  the  material  of  the  tissue  still  removed  in  visible  sloughs  or 
fragments  ?  Certainly  it  is  so  sometimes ;  for  we  may  find  little  frag- 
ments of  bone  in  the  discharge  from  ulcerating  bone,  especially  in  stru- 
mous ulceration.  But  in  other  cases  we  have  no  evidence  of  this  kind; 
we  cannot  detect  even  microscopic  fragments  of  tissues  in  the  discharges; 
and  we  must  suppose  that  they  are  removed,  in  a  state  of  solution  or  of 
molecular  division,  in  the  discharge  from  the  diseased  part.  * 

To  speak  of  the  solution  of  tissues  in  the  discharges  of  ulcers  may 
seem  like  the  revival  of  an  old  error  long  since  disproved.  But  though 
the  expression  may  be  revived,  it  is  with  a  new  meaning.  The  proof 
has,  truly,  been  long  completed,  that  healthy  tissues,  even  though  they 
be  dead,  cannot  be  dissolved  in  pus,  or  any  such  discharge ;  but  the 
tissues  that  bound  or  form  the  walls  of  a  spreading  ulcer  are  not 
healthy  ;  they  are  inflamed,  and,  as  I  have  been  just  saying,  their  ele- 
ments, and  the  products  of  inflammation  in  and  among  them,  are  dege- 
nerate, so  that  they  may  be  now  minutely  divided,  or  even  soluble  in 
fluids  that  could  not  dissolve  them  while  they  were  sound.  Insolubility 
is  as  great  an  obstacle  to  absorption  as  to  ejection  in  discharges ;  no 
tissue  can  be  absorbed  without  being  first  so  far  changed  as  to  be  solu- 
ble or  very  minutely  divided  in  fluids  with  which  it  was  before  in  con- 
tact and  unharmed.  Therefore,  whether  we  hold  the  ordinary  spreading 
of  an  ulcer  to  be  by  absorption  of  its  boundaries,  or  ascribe  it  to  their 
ejection,  we  must,  in  either  case,  admit  that  they  are  first  made  soluble. 
And  if  this  be  admitted,  then  it  is  most  consistent  with  analogy,  and 
most  probable,  that  the  extension  of  an  ulcer,  independently  of  slough- 
ing, is  accomplished  by  the  gradual  degeneration  of  the  tissues  that 
form  its  walls,  and  by  their  being  either  disintegrated  and  cast  off  in 
minute  molecular  matter,  or  else  dissolved  and  ejected  in  solution  in 
the  discharges  from  the  ulcer. 

The  solution  here  spoken  of  is  such  as  may  be  effected  by  the  fluid 
discharged  from  any  spreading  ulcers ;  but  we  may  doubt  whether  all 
discharges  from  ulcers  possess  a  corroding  property,  such  as  Rokitansky 
seems  to  ascribe  to  them,  and  such  as  he  considers  to  be  the  chief  cause 
of  the  extension  of  all  ulcers.  We  may  doubt,  I  say,  whether  all 
ulceration  can  be  described  as  a  corrosion  or  erosion  of  the  tissues  by 
ichor ;  but,  on  the  other  side,  we  cannot  well  doubt  that  the  properties 
of  the  discharge  from  an  ulcer,  or  a  sloughing  sore,  may  have  a  great 
influence  in  accelerating  the  degeneration  and  decomposition,  and 
thereby  the  solution,  of  the  tissues  that  form  its  walls  or  boundaries. 

*  The  observations  of  Professor  Goodsir  (op.  cit.  p.  15),  tend  to  show  that  the  disap- 
pearance of  the  textures  of  an  ulcerated  surface  is  due  to  the  rapid  formation  of  a  layer  of 
cells  on  the  surface  and  at  the  margin  of  the  ulcer,  which  cause  the  destruction  of  the  nor 
mal  textures,  either  by  previous  solution  and  subsequent  absorption  of  the  latter,  or  by  the 
vigorous  growth  of  the  cells  monopolizing  the  proper  resources  of  the  part,  so  that  it  gradu- 
ally dissolves  and  disappears. 


292  HEALING    OF    ULCERS. 

Many  ichorous  discharges  from  ulcers  inflame  and  excoriate  the  parts 
over  which  they  flow,  and  thus  inflaming  them,  they  promote  their  de- 
generation, and  lead  them  more  readily  to  enter  into  the  ulcerative 
process.  Many  such  discharges,  also,  are  in  an  active  state  of  decom- 
position ;  and  their  contact  with  the  inflamed  tissues  cannot  but  have 
some  tendency  to  excite  decomposition  in  them ;  a  tendency  which  the 
tissues  will  be  the  less  able  to  resist,  in  the  same  proportion  as  they  are 
already  feebly  maintaining  themselves,  or  as  they  have  been  moved  by 
inflammation  from  their  normal  conditions  and  their  normal  tenacity  of 
composition. 

On  the  whole,  then,  we  may  conclude,  respecting  the  process  of 
ulceration,  that  its  beginning  is  usually  the  detachment  of  a  slough,  or 
portion  of  dead  tissue,  by  the  removal  of  the  layer  of  living  tissue  that 
bounded  it ;  that  the  spreading  of  an  ulcer,  independent  of  such  visible 
sloughing,  is  effected  by  the  inflamed  tissues  that  bound  it  becoming 
degenerate,  and  being  detached  in  minute  particles,  or  molecular  mat- 
ter, or  being  decomposed  and  dissolved  in  the  fluid  discharge  or  ichor ; 
and  that  this  spreading  may  be  accelerated  by  the  influence  of  the  dis- 
charge itself,  which  may  inflame  the  healthy  tissues  that  it  rests  on, 
and  may  exercise  a  decomposing  "catalytic"  action  on  those  that  are 
inflamed  already. 

I  need  hardly  say  that  we  have  no  knowledge  by  which  to  explain 
the  peculiar  and  characteristic  forms  of  certain  ulcers.  We  seem 
wholly  without  a  guide  to  such  knowledge ;  but  the  existence  of  such 
specific  forms  is  conclusive  against  the  supposition  that  the  extension 
of  an  ulcer  is  entirely  due  to  corrosion  by  an  exuded  fluid.  Such  a 
fluid  would  act  uniformly,  unless  the  various  effects  of  disease  on  the 
tissues  bounding  the  ulcer  should  make  them  variously  amenable  to  its 
influence. 

We  have  as  little  knowledge  of  the  nature  and  real  differences  of  the 
various  fluids  discharged  from  ulcerating  surfaces, — the  various  kinds  of 
ichor*  that  they  yield.  They  consist,  generally,  of  fluid  exuded  from 
the  surface  as  an  inflammatory  product,  and  holding  in  suspension  or 
solution  the  disintegrated  materials  of  the  ulcerating  tissue,  and  of  the 
lymph  infiltrated  in  them.  The  inflammatory  product  exuded  on  a 
spreading  ulcer  has,  indeed,  the  constituents  of  lymph  or  pus  ;  but  they 
appear  immature  or  degenerate,  consisting  of  abundant  molecular  mat- 
ter, with  flakes  of  soft,  dotted  fibrine,  and  ill-formed  lymph-  or  pus-cells, 
floating  in  an  excess  of  liquid.     Such  a  substance  is,  probably,  always 

*  I  think  it  would  be  useful  to  employ  the  term  ichor  exclusively  for  those  discharges 
mixed  with  exudation  that  take  place  from  ulcerating,  i.  e.,  from  progressively  ulcerating  or 
sloughing  surfaces.  For,  although  it  may  be  often  impossible  to  distinguish,  by  any  mani- 
fest properties,  sucll'  ichor  from  some  of  the  thinner  kinds  of  pus,  yet,  if  the  account  of 
suppuration  and  of  ulceration  be  true,  a  constant  difference  between  pus  and  ichor  will 
be,  that  the  latter  contains  disintegrated  materials  of  the  ulcerating  tissue,  the  former 
does  not. 


NATURE    AND    CAUSES    OF    INFLAMMATION.  293 

incapable  of  organization,  both  because  of  its  own  defect,  and  because 
of  the  inflamed  state  of  the  parts  it  is  in  contact  with.  The  differences 
that  may,  from  the  first,  exist  in  the  several  examples  of  ichor  are 
moreover  quickly  increased  by  the  various  chemical  transformations 
that  they  undergo.  Rokitansky  alone  has  endeavored  to  enumerate 
the  varieties  of  property  that  may  hence  issue,  and  the  influences  they 
may  exercise  in  the  maintenance  of  the  disease.* 

As  from  other  inflammatory  processes,  so  from  ulceration,  we  may 
trace  the  transitions  to  the  healing  process.  In  the  case  of  ulcerated 
cartilage.  Dr.  Redfern's  researches  show  that  the  healing  is  accom- 
plished, mainly,  by  the  complete  transformation  of  the  remaining  car- 
tilage-substance into  fibrous  tissue.  Here  is  no  proper  process  of 
exudation,  for  here  are  no  interstitial  bloodvessels ;  the  materials  of 
the  tissue  itself,  by  transformation,  form  the  scar. 

But  in  the  vascular  tissues,  the  reparative  material  is  the  lymph  in- 
filtrated in  them  at  and  near  the  boundaries  of  the  ulcer.  As  the  in- 
flammation subsides  (for  here,  as  in  other  cases,  the  inflammation  that 
produced  the  lymph  must  cease  for  its  development),  the  lymph  passes 
through  changes  like  those  described  in  the  abscess-wall,  and  the  tissues 
in  which  it  was  infiltrated  may,  perhaps,  recover  from  their  degenera- 
tion. Part  of  the  lymph,  increased  by  fresh  exudation,  assumes  the 
characters  of  granulations,  which,  as  we  watch  the  progress  of  an  im- 
proving ulcer,  assume  daily  more  of  the  characters  of  those  on  healing 
open  wounds.  We  cannot,  indeed,  mark  the  very  act,  or  tell  the  hour, 
at  which  the  inflammatory  process  was  changed  for  the  reparative ;  at 
which  the  degeneration  ceased,  and  development  began  ;  there  are  no 
hard  boundary  lines  here,  or  in  any  passage  from  disease  to  health  ;  but 
the  change  is  gradually  accomplished,  and  is  manifest  both  in  the  organi- 
zing material  of  the  granulations,  and  in  the  pus  which  takes  the  place 
of  the  ichor,  and  exactly  resembles  that  of  the  healing  granulating  wound. 
The  ulcer  is  no  longer  ulcerating,  but  healing ;  and  the  histories  of  the 
healing  ulcer,  and  of  the  healing  wound,  might  be  told  in  the  same 
words. 


LECTURE  XVIII. 

NATURE    AND    CAUSES    OF   INFLAMMATION. 

The  several  parts  of  the  inflammatory  process  have  been  now  con- 
sidered. They  are, — increased  fulness  of  the  bloodvessels,  with  re- 
tarded movement  of  the  blood ;  swelling ;  pain,  or  other  morbid  exalted 
sensation ;  increased  heat ;  exudation  of  lymph  from  the  bloodvessels  ; 
defective  nutrition  of  the  proper  elements  of  the  affected  part.     The 

*  Pathologische  Anatomie,  B.  i,  p.  213. 


294  NATURE    AND    CAUSES     OF    INFLAMMATION. 

first  five  are  often  spoken  of  as  the  signs  of  inflammation,  the  last  two 
as  its  effects ;  but  these  terms  have  reference  only  to  the  former  being 
more  transitory  phenomena  than  the  latter :  they  are  all,  when  they 
concur,  constituent  parts  of  the  disease ;  but  the  latter  are  less  quickly 
recovered  from  than  the  former. 

It  would  not  be  judicious,  I  think,  to  refuse  to  call  that  process  in- 
flammation, in  which  any  one  of  the  conditions  just  enumerated  is  ab- 
sent or  unobserved.  Swelling,  or  pain,  or,  much  oftener,  increased  heat, 
may  be  inappreciable  in  tissues  that  we  may  still  rightly  call  inflamed, 
while  the  other  evidences  of  the  disease  are  present.  The  same  maybe 
said  of  increased  or  altered  exudation  from  the  bloodvessels.  No  such 
exudation  is  observed  in  the  diseased  cornea  or  articular  cartilages  ;  but 
it  would  be  unreasonable,  in  the  case  of  an  inflamed  eye,  to  say  that  the 
changes  are  due  to  inflammation  in  every  part  but  the  cornea;  and  to 
call  the  process  leading  to  the  ulceration  or  leucoma  of  the  cornea  by  a 
name  diff"erent  from  that  which  we  give  to  the  coincident  and  similarly 
excited  process  in  the  other  tissues.  So,  during  the  inflammation  of  a 
joint,  it  would  be,  at  the  least,  inconvenient  to  say  that  all  the  tissues 
are  inflamed  except  the  softening  or  ulcerating  cartilages.  The  pro- 
gressive degeneration  of  tissue  is,  probably,  never  absent  when  the 
other  parts  of  the  inflammatory  process  exist ;  but,  in  quickly  transi- 
tory cases,  it  is  often  inappreciable.  The  altered  state  of  the  circula- 
tion may  be  unobserved :  but  it  is,  probably,  always  present ;  for  in  the 
case  of  the  parts  that  have  no  interstitial  bloodvessels,  inflammation 
may  still  be  attended  by  enlargement  of  those  of  adjacent  parts  on 
which  their  ordinary  nutrition  depends. 

The  conclusion,  then,  may  be,  that  in  what  may  be  regarded  as  well- 
marked,  or  typical  examples  of  inflammation,  all  the  characters  I  have 
enumerated  are  present  as  concurrent  parts  of  the  disease;  but  that  the 
same  name  should  not  be  refused  to  diseases  in  which  any  one  of  these 
parts  is  absent  or  unobserved,  especially  when  its  absence  may  be 
explained,  as  in  the  case  of  inflamed  cartilages,  by  some  peculiarity  of 
tissue  or  other  condition  of  the  disease.  I  think  it  would  not  be  right 
to  call  any  process  inflammation  in  which  there  is  neither  an  exudation 
of  lymph  (^'.  e.  of  material  capable  of  such  developments  or  degenerations 
as  I  have  described),  nor  a  deterioration  of  a  proper  tissue  of  the  aff'ected 
part ;  even  though  the  other  characters  of  the  disease  might  be  present. 
But,  really,  whatever  rule  of  nomenclature  be  adopted,  we  may  expect 
to  meet  with  many  cases  in  which  we  shall  doubt  what  name  to  give  to 
the  processes  which  we  watch,  or  of  which  we  see  the  results.  There 
is  neither  here,  nor  in  any  other  part  of  pathology,  anything  like  the 
unity,  or  circumscription,  of  species  by  which  the  zoologist,  whose 
nomenclature  pathologists  are  prone  to  imitate,  is  justified  in  attaching 
to  each  specific  name  the  idea  of  several  constant  and  unalterable  cha- 
racters in  the  beings  to  which  it  is  assigned. 


NATURE    AND     CAUSES     OF    INFLAMMATION.  295 

An  examination  of  the  very  nature  of  the  process  of  inflammation 
may  best  be  made  in  the  form  of  a  comparison  of  its  efiects  with  those 
of  the  normal  process  of  nutrition.  And  this  comparison  maybe  draAvn 
with  two  principal  views ;  namely,  to  determine — Isfc,  how  the  efi'ects 
of  inflammation  difi"er,  in  respect  of  quantity,  from  those  of  the  normal 
process ;  and  2d,  how  they  difl"er  from  the  same,  in  respect  of  quality 
or  method. 

The  decision  on  the  first  of  these  points  may  seem  to  be  given  in  the 
term  "increased  action,"  which  is  commonly  used  as  synonymous  with 
inflammation.  As  used  by  Mr.  Hunter,  this  term  was  meant  to  imply 
that  the  small  vessels  of  an  inflamed  part  are  more  than  naturally  active, 
in  formation  or  absorption,  or  in  both  these  processes.  This  is,  proba- 
bly, the  meaning  still  generally  attached  to  the  term  by  some  ;  while, 
as  employed  by  those  who  believe  the  vessels  are  only  accessories  in  the 
work  of  nutrition,  the  expression  "  increased  action"^may  be  used  to 
imply  merely  increased  formation,  or  increased  absorption.  In  either, 
or  in  any,  meaning,  however,  the  term  seems  to  involve  the  idea  of  an 
increased  exercise  of  vital  forces,  i.  e.  of  those  forces  through  the  opera- 
tion of  which  the  various  acts  of  organic  formation  are  accomplished. 
But,  if  "  increased  action"  is  to  imply  this,  the  description  of  the  process 
and  efi'ects  of  inflammation  shows  that  the  term  cannot  be  properly  used, 
without  some  limit  or  qualification. 

If  we  consider  the  quantity  of  organic  formation  efi'ected  during  the 
infiammatory  process,  in  the  proper  substance  of  the  infiamed  part,  it 
is  evidently  less  than  in  health.  All  the  changes  described  in  the  last 
lecture  are  examples  of  diminished  or  suspended  nutrition  in  the  tissues 
of  the  inflamed  part :  they  are  all  characteristic  of  atrophy,  degenera- 
tion, or  death.  The  tissues  become  soft,  or  quite  disorganized ;  they 
are  relaxed  and  weakened ;  they  degenerate,  and  remain  lowered  at  once 
in  structure,  chemical  composition,  and  functional  power ;  or  else,  after 
degeneration,  they  are  absorbed,  or  are  disintegrated,  or  dissolved,  and 
cast  out;  they  die  in  particles  or  in  the  mass.  During  all  the  processes 
of  inflammation  there  is  no  such  thing  as  an  increased  formation  of  the 
natural  structures  of  the  inflamed  part ;  they  are  not  even  maintained ; 
their  nutrition  is  always  impaired,  or  quite  suspended.  It  is  only  after 
the  inflammation  has  ceased  that  there  is  an  increased  formation  in 
some  of  the  lowly  organized  tissues,  as  the  bones  and  connective  tissue. 

So  far,  then,  as  the  proper  substance  of  the  inflamed  part  is  con- 
cerned, there  appears  to  be  decreased  action ;  that  is,  decreased  forma- 
tion. There  may  be,  indeed,  an  increased  absorption  ;  but  this  is  also,  in 
one  sense,  characteristic  of  decreased  exercise  of  vital  force ;  since  all 
absorption  implies  a  previous  degeneration  of  the  part  absorbed.  Nor 
can  we  justly  call  this,  in  any  sense,  "increased  action,"  till  we  can  show 
how  absorption  is  an  action  of  vessels. 

Thus  far,  one  of  the  constituents  of  the  inflammatory  process,  one  of 


296  NATURE    AND     CAUSES    OF    INFLAMMATION. 

the  characters  in  which  it  differs,  in  respect  of  quantity,  from  normal 
nutrition,  is  a  defect  in  the  nutrition  of  the  proper  substance  of  the 
inflamed  part. 

But  it  is  characteristic  of  the  complete  process  of  inflammation,  that, 
while  the  inflamed  structure  itself  suffers  deterioration,  there  is  a  pro- 
duction of  material  which  may  be  peculiarly  organized.  Here,  there- 
fore, may  be  an  evidence  of  increased  formation,  of  increased  action. 

Doubtless  in  relation  to  the  productive  part  of  the  inflammatory  pro- 
cess, the  expression  "increased  action"  may  be  in  some  sense  justly  used ; 
for  the  weight  of  an  inflamed  part,  or  of  the  material  separated  from  it, 
may  be  much  increased  by  the  formation  of  organized  matter.  But  the 
quantity  of  organized  matter  formed  in  an  inflammation  must  not  be 
unconditionally  taken  as  a  measure  of  increase  in  the  exercise  of  the 
vital  forces;  for  it  is  to  be  observed,  that  the  material  formed  presents 
only  the  lowest  grades  of  organization,  and  that  it  is  not  capable  of 
development,  but  rather  tends  to  degeneration,  so  long  as  the  inflam- 
mation lasts. 

It  may  be  but  a  vague  estimate  that  we  can  make  of  the  amount  of 
force  exercised  in  any  act  of  formation ;  yet  we  may  be  sure  that  a 
comparatively  small  amount  is  sufficient  for  the  production  of  low  organ- 
isms, such  as  are  the  fibrinous  and  corpuscular  lymphs  of  inflammation. 
The  abundant  production  of  lowly  organized  structures  is  one  of  the 
features  of  the  life  of  the  lowest  creatures,  in  both  the  vegetable  and 
animal  kingdoms.  And  in  our  own  cases,  a  corresponding  abundant 
production  is  often  noticed  in  the  lowest  states  of  vital  force ;  witness 
the  final  inflammations,  so  frequent  in  the  last  stages  of  granular- de- 
generation of  the  kidneys,  of  phthisis,  of  cancer,  and  other  exhausting 
diseases.  In  all  these,  even  large  quantities  of  the  lowly  organized 
cells  of  inflammatory  lymph  may  be  formed,  when  life  is  at  its  last  ebb. 
And  with  these  cases  those  correspond  which  show  the  most  rapid  in- 
crease of  tubercle  and  cancer,  and  of  lowly  organized  tumors,  when  the 
health  is  most  enfeebled,  and  when  the  blood  and  all  the  natural  struc- 
tures are  wasting. 

From  these  considerations  we  may  conclude  that  the  productive  part 
of  the  inflammatory  process  is  not  declaratory  of  the  exercise  of  a  large 
amount  of  formative  or  organizing  force ;  and  this  conclusion  is  con- 
firmed by  observing  that  development,  which  always  requires  the 
highest  and  most  favored  exercise  of  the  powers  of  organic  life,  does 
not  occur  while  inflammation  lasts.  The  general  conclusions,  therefore, 
may  be,  as  well  from  the  productive  as  from  the  destructive,  effects  of 
the  inflammatory  process,  that  it  is  accomplished  with  small  expenditure 
of  vital  force ;  and  that  even  when  large  quantities  of  lymph  are  lowly 
organized,  such  an  expression  as  "  increased  action"  cannot  be  rightly 
used,  unless  we  can  be  sure  that  the  defect  of  the  formative  power,  ex- 
ercised in  the  proper  tissue  of  the  inflamed  part,  is  more  than  counter- 


NATURE    AND     CAUSES    OF    INFLAMMATION.  297 

balanced  by  the  excess  employed  in  the  production  and  low  organization 
of  lymph. 

It  may  be  said  that  the  signs  of  inflammation  are  signs  of  increased 
action.  But  these  are  fallacious,  if,  again,  by  increased  action  be  meant 
any  increased  exercise  of  vital  force.  The  redness  and  the  swelling 
of  the  inflamed  part  declare  the  presence  of  more  blood  ;  but  this  blood 
moves  slowly  ;  and  it  is  a  quick  renewal  of  blood,  rather  than  a  large 
quantity  at  any  time  in  a  part,  that  is  significant  of  active  life.  An 
abundance  of  blood,  with  slow  movement  of  it,  is  not  characteristic  of 
activity  in  a  part ;  it  often  implies  the  contrary,  as  in  the  erectile  tis- 
sues, and  the  cancellous  tissue  of  bone. 

The  local  increase  of  heat  is  too  inconstant  to  afi"ord  ground  for  judg- 
ing of  the  nature  of  inflammation.*  When  manifest,  it  is  not,  I  think, 
to  be  exactly  compared  with  that  of  an  actively  growing  part,  or  of  one 
which  is  the  seat  of  "  determination"  of  blood,  or  of  "  active  congestion." 
In  these  cases  the  heat  is  high  chiefly  because  the  blood,  brought  quickly 
from  the  heart,  is  quickly  renewed ;  but,  in  an  inflamed  part,  the  blood 
is  not  so  renewed  ;  it  moves  more  slowly.  The  heat  may,  indeed,  be  in 
some  measure  ascribed  to  this  condition ;  for  the  quickly  moving  blood 
around  the  inflamed  part  may  communicate  its  heat  to  that  which  is 
moving  more  slowly.  But  the  proper  heat  of  inflammation  (I  mean  that 
which  is  measurable  by  the  thermometer),  cannot,  I  think,  be  wholly 
thus  explained.  Some  of  it  is,  probably,  due  to  the  oxidation  of  the 
degenerating  tissues  ;  a  process  which  we  might  safely  assume  to  be 
rapidly  going  on  in  the  more  destructive  inflammations,  and  which  is, 
indeed,  nearly  proved  by  some  of  the  evidences  of  the  increased  excre- 
tion of  oxidized  substances  in  inflammations,  especially  by  the  increase 
of  phosphates  in  the  urine  during  inflammation  of  the  brain. f  It  is  far 
from  proved,  indeed,  that  this  source  of  heat  is  sufficient  for  the  expla- 
nation of  the  increase  in  an  inflamed  part ;  and  it  may  be  at  once  ob- 
jected that  we  have  no  evidence  that  the  hottest  inflamed  parts  are 
those  in  which  the  most  destructive  processes  are  going  on.  Still,  in 
relation  to  the  question,  how  far  the  increased  heat  is  a  sign  of  the 
quantity  of  formative  force  that  is  being  exercised,  we  may  argue  that, 
as  the  general  supply  of  heat  in  our  bodies  is  derived  from  oxidation 
or  combustion  of  wasted  tissues  or  of  surplus  food,  so  in  these  local 
augmentations  of  heat,  the  source  is  rather  from  similar  destruction  of 
organized  substances  than  from  increased  formation  of  them.  If  it  be 
so,  the  increased  heat  will  give  no  ground  for  regarding  the  inflamma- 
tory process  as  the  result  of  a  greater  exercise  of  formative  force  than 
is  employed  in  ordinary  nutrition  ;  none  for  speaking  of  it  as  increased 
nutrition  or  increased  action.     Rather,  this  sign  may  be  added  to  the 

*  See,  especially,  v.  Barensprung  in  Miiller's  Archiv,  1852,  p.  268. 

■j"  Dr.  Bence  Jones:  On  the  contrast  between  Delirium  Tremens  and  Inflammation  of  ths- 
Brain,  Med.-Chir.  Trans,  vol.  xxx,  p.  37 ;  and  Virchow,  in  his  Archiv,  B.  iv,  H.  1. 

20 


298  NATURE    AND    CAUSES    OF    INFLAMMATION. 

evidences,  that  the  inflammatory  process  presents,  of  diminished  forma- 
tive force,  and-  of  a  premature  and  rapid  degeneration,  in  the  affected 
part. 

In  thus  endeavoring  to  estimate  the  difference  between  the  normal 
and  the  inflammatory  modes  of  nutrition  in  regard  to  the  quantity  of 
formative  or  other  vital  force  exercised  in  them  respectively,  I  have 
also  stated  the  chief  differences  in  relation  to  the  quality  or  method  of 
nutrition. 

The  most  general  peculiarity  of  the  inflammatory  method  is  the  con- 
currence of  the  two  distinct,  though  usually  coincident,  events  of  which 
I  have  spoken  at  such  length ;  namely,  1st,  the  impairment  or  suspen- 
sion of  nutrition  of  the  proper  substance  of  the  inflamed  part ;  and  2d, 
the  exudation,  from  the  blood,  of  a  material  more  than  sufl&cient  in 
quantity  for  the  nutrition  of  the  part,  but  less  than  sufficient  in  its 
capacity  of  development. 

By  these  concurring,  it  is  plainly  distinguished  from  the  normal 
method  of  nutrition.  The  same  combination  of  events  establishes  the 
chief  differences  between  the  inflammatory  and  every  other  mode  of 
nutrition  in  a  part.  Thus,  from  all  the  forms  of  mere  atrophy  or  de- 
generation, the  inflammatory  process,  at  least  in  the  typical  examples, 
is  distinguished  by  the  production  of  the  lymph,  which  may  be  organ- 
izing, even  while  the  proper  tissue  of  the  inflamed  part  is  in  process 
of  atrophy,  degeneration,  or  absorption.  So  far  as  the  tissues  inflamed 
are  concerned,  some  inflammations  might  be  classed  with  atrophies  or 
degenerations ;  but  the  concurrent  production  of  lymph  is  distinctive 
of  them. 

On  the  other  side,  the  inflammatory  mode  of  nutrition  is  distin- 
guished from  hypertrophy  by  the  failure  of  the  nutrition  of  the  in- 
flamed part  itself.  So  far  as  mere  production  and  formation  of  organ- 
isms are  concerned,  some  inflammations  might  be  paralleled  with 
hypertrophies ;  but  the  organization  of  the  lymph  commonly  falls  short 
of  that  proper  to  the  part  in  which  it  is  exuded ;  and  the  substance  of 
the  part,  instead  of  being  augmented,  is  only  replaced  by  one  of  lower 
organization. 

And,  lastly,  from  the  production  of  new  growths,  such  as  tumors, 
the  inflammatory  process  is  distinguished  by  this, — that  its  organized 
products,  though  like  natural  tissues  of  the  body,  are  usually  infiltrated, 
fused,  and  interwoven  into  the  textures  of  the  inflamed  part ;  and  that, 
when  once  their  development  is  achieved,  they  have  no  tendency  to  in- 
crease in  a  greater  ratio  than  the  rest  of  the  body. 

I  am  well  aware  that  these  can  be  accepted  as  only  the  generally 
distinguishing  characters  of  the  complete  inflammatory  process.  Cases 
might  be  easily  adduced  in  which  the  border  lines  are  obscured ;  in- 
flammations confounded  on  one  side  with  atrophies,  on  another  with 
hypertrophies,  on  a  third  with  tumors,  and  on  others,  with  yet  other 


NATUKE    AND    CAUSES    OF    I^STFL  AM  M  ATIOX.  299 

local  phenomena  of  disease.  But  the  same  difficulties  are  in  every 
department  of  our  science ;  yet  we  must  acknowledge  the  value  of 
general  distinctions  among  diseases  even  more  alike  than  these  are. 

The  case  that  I  have  chosen  for  illustrating  the  general  nature  of  the 
imflammatory  process  is  one  representing  the  disease  in  its  simplest 
form  and  earliest  stage,  manifesting  only  the  formation  of  lymph,  and 
such  a  change  as  the  softening  or  absorption  of  the  inflamed  part.  This 
is  hut  the  beginning  of  the  history  :  but,  if  the  inflammation  continues, 
or  increases,  in  severity,  all  that  follows  is  consistent  with  this  begin- 
ning; all  displays  the  same  double  series  of  events,  the  same  defective 
nutrition  of  the  part,  and  the  same  production  of  low  organisms.  But 
these  additions  are  observed  :  the  part  is  more  and  more  deteriorated, 
and  perishes  in  the  mass,  or  in  minute  fragments ;  the  newly-organized 
products,  not  finding  the  necessary  conditions  of  nutrition,  partake  in 
the  degenerative  process,  and,  instead  of  being  developed,  are  degene- 
rated into  pus,  or  some  yet  lower  forms,  or  perish  with  the  tissues  in 
which  they  are  imbedded. 

Respecting  now  the  causes  of  inflammation,  I  shall  not  say  more  of 
its  exciting  causes  than  that  from*  the  external  ones,  which  alone  we 
can  at  all  appreciate,  we  may  derive  a  confirmation  of  the  opinion  I 
have  expressed  concerning  the  nature  of  the  process.  They  are  such 
as  would  be  apt  to  produce  depression  of  the  vital  forces  in  a  part ;  all 
being,  I  think,  such  as,  when  applied  with  more  severity,  or  for  a  longer 
time,  lead,  not  to  inflammation,  but  to  the  death  of  the  part.  If  a  cer- 
tain excess  of  heat  will  inflame,  a  certain  yet  greater  heat  will  kill :  if 
some  violence  will  inflame,  a  greater  violence  will  kill :  if  a  diluted 
chemical  agent  will  only  irritate,  the  same  concentrated  will  destroy  the 
part.  The  same  may  be  said,  I  think,  of  cold,  and  all  the  other  external 
exciting  causes  of  inflammation.  I  am  aware  that  other  explanations 
of  their  action  are  given ;  but  none  seems  to  me  so  simple,  or  so  consis- 
tent with  the  nature  of  the  process  that  follows  them,  as  this  which 
assumes  that  they  all  tend  (as  it  may  be  said)  to  depress  the  vital  forces 
exercised  in  the  afi"ected  part.  They  may  be  stimulants  or  excitants  of 
the  sensitive  nerves  of  the  part,  but  they  lead  to  the  opposite  of  ac- 
tivity in  its  nutritive  processes.  In  the  reaction  which  follows  the  appli- 
cation of  some  of  them,  they  may  seem  to  have  been  the  excitants  of 
nutritive  action  ;  but,  if  the  inflammatory  state  ensue,  the  formative 
process,  we  have  seen,  is  really  diminished. 

The  proximate  causes,  or  immediately  preceding  conditions,  of  in- 
flammation appear  to  be  various  perversions  of  the  necessary  conditions 
of  healthy  nutrition  in  a  part ;  that  is,  morbid  changes  in  either  the 
supply  of  blood,  the  composition  of  the  blood,  the  influence  of  the  ner- 
vous force,  or  the  condition  of  the  proper  substance  of  the  inflamed 
part.  Any  one  or  more  of  these  four  conditions  of  nutrition  being 
changed  in  quality  may  initiate  an  inflammation.    A  change  in  quantity 


300  NATURE    AND    CAUSES    OF    INFLAMMATION. 

more  usually  produces  either  an  excess  or  deficiency  of  nutrition  in  the 
part,  or  some  process  different  from  inflammation.  Thus,  a  diminution 
or  withdrawal  of  the  blood,  without  alteration  of  its  quality,  is  usually 
followed  by  atrophy,  degeneration,  or  death  :  a  mere  increase  of  blood 
in  a  part  may  produce  hypertrophy,  or  something  more  nearly  resem- 
bling inflammation,  yet  falling  short  of  it.  Similar  effects  may  ensue 
from  a  mere  increase  or  decrease,  or  abstraction,  of  nervous  force. 
Change  in  the  quality,  whether  with  or  without  one  in  the  quantity,  of 
the  conditions  of  nutrition,  appears  essential  to  the  production  of  the 
phenomena  of  inflammation. 

I  will  endeavor  now  to  show  that  inflammation  may  follow  such  per- 
version or  qualitative  change  in  each  of  the  conditions  of  nutrition, 
even  though  all  the  rest  of  them  remain  for  a  time  in  their  normal 
state :  selecting,  for  this  purpose,  such  cases  of  inflammation  as  we  may 
trace  proceeding,  in  the  first  instance,  from  the  uncomplicated  error  of 
a  single  condition  of  nutrition. 

I.  Inflammation  may  perhaps  be  produced, — it  certainly  may  be 
commenced,  and  in  some  measure  imitated, — by  changes  in  the  blood- 
vessels ;  changes  attended  with  alteji'ation  of  their  size,  or  their  permea- 
bility, or  the  other  qualities  by  which  they  affect  the  supply  of  blood 
to  a  part.  This  may  be  concluded  from  the  similarity  to  some  of  the 
phenomena  of  inflammation  which  may  be  observed  in  certain  cases  of 
mechanical  obstruction  to  the  venous  circulation.  In  a  case  of  ascites 
from  diseased  heart  or  liver,  the  peritoneum  often  contains  coagula  of 
fibrine  floating  free  in  the  serum,  though  no  organ  may  present  appear- 
ances of  having  been  inflamed.  In  such  a  case,  moreover,  I  have  found 
the  fibrine  deveteping  itself  in  the  form  of  nucleated  blastema,  even 
while  floating  free.  In  another  case  of  mechanical  dropsy,  I  have  found 
the  fluid  of  anasarca  in  the  scrotum  containing  both  fibrine  and  abun- 
dant lymph-corpuscles,  like  those  in  the  fluid  of  an  inflammatory  exu- 
dation. In  like  manner  an  apparently  uncomplicated  obstruction  at 
the  left  side  of  the  heart  may  produce  many  of  the  phenomena  of 
bronchitis.  Such  as  these  are  the  cafses  through  which  mechanical  con- 
gestions of  blood  connect  themselves  with  inflammation.  And  if  to 
these  we  add  the  constancy  of  increased  vascularity  among  the  phe- 
nomena of  inflammation,  they  may  be  sufficient  to  make  us  believe,  that 
disturbances  in  the  circulation  of  a  part  may  produce  some  of  the  prin- 
cipal phenomena  of  inflammation,  even  though  all  the  other  conditions 
of  nutrition  are,  in  the  first  instance,  unchanged.  But  I  know  no  other 
good  evidence  for  the  belief;  and  I  think  we  should  not  lay  much  stress 
on  these  cases,  since  they  display  an  imitation  of  only  some  parts  of 
the  process  of  inflammation ;  namely,  the  fulness  of  the  vessels,  the  re- 
tarded blood,  and  the  exudation  of  organizable  matter.  The  nutrition 
of  the  proper  tissues  of  a  part  with  merely  obstructed  circulation  suffers 
but  a  trivial  loss  or  disturbance,  in  comparison  with  that  which  would 


NATURE  AND  CAUSES  OF  INFLAMMATION.       301 

accompany  an  inflammation  with  an  equal  amount  of  retardation  in  the 
movement  of  the  blood.  So  far  as  the  exudation  in  an  inflamed  part 
depends  on  the  altered  mechanical  relations  of  the  blood  and  vessels, 
so  far  may  similar  alterations  alone  produce  efi"ects  imitating  those  of 
inflammation  ;  they  may  also  be  the  beginning  of  the  more  complete 
process  ;  but  I  believe  that  the  merely  mechanical  disturbances  of  the 
circulation  are  no  more  adequate  alone  to  the  explanation  of  the  whole 
process  of  inflammation,  than  the  normal  movements  of  the  blood  are 
adequate  to  the  explanation  of  the  ordinary  process  of  nutrition.* 

II.  We  may  speak  much  less  equivocally  of  the  influence  of  the  state 
of  the  blood  itself  in  causing  inflammations ;  for  there  can  be  little 
doubt  that  a  very  great  majority  of  the  so-called  spontaneous  or  con- 
stitutional, as  distinguished  from  traumatic  inflammations,  have  herein 
their  origin.  We  might  anticipate  this,  from  the  consideration  that,  in 
normal  nutrition,  the  principal  factors  are  the  tissues  and  the  blood  in 
their  mutual  relations :  but  we  have  better  evidence  than  this,  in  cases 
of  local  inflammations  occurring  in  consequence  of  general  diseases  of 
the  blood.  Some  instances  of  this  are  clearly  proved,  as,  e.  g.  in  the 
cases  of  eruptive  fevers,  when  the  presence  of  morbid  materials  in  the 
blood  is  proved  by  the  eff'ects  of  their  transference  in  inoculation. 
Scarcely  less  thoroughly  demonstrated  are  the  cases  of  rheumatism 
and  gout,  of  lepra,  psoriasis,  herpes,  eczema,  erysipelas,  and  other 
such  afi"ections,  whose  constitutional  nature, — in  other  words,  whose 
primary  seat  in  the  blood, — all  readily  acknowledge  in  practice,  if  not 
in  theory. 

Now,  in  all  these  cases,  local  inflammations  are  the  external  signs  of 
the  general  affection  of  the  blood ;  and  I  apprehend,  that  if  any  diffi- 
culty be  felt  in  receiving  these  as  evidences  that  the  morbid  condition 
of  the  blood  is  the  cause  of  the  local  inflammation,  it  will  be  throug-h 
doubt  whether  a  general  disease  of  the  blood — a  disease  affecting  the 
blood  sent  to  every  part — can  produce  peculiar  phenomena  of  disease 
in  only  certain  small  parts  or  organs.  But  this  local  eff"ect  of  a  gene- 
ral disease  of  blood  has  its  illustration  in  some  of  the  sure  principles  of 
physiology ;  especially  in  one  which  I  have  fully  illustrated  in  a  former 
lecture  (p.  40  et  seq.  and  p.  63) ;  namely,  that  the  presence  of  certain 
materials  in  the  blood  may  determine  the  formation  of  appropriate  or- 
ganisms, in  which  they  may  be  incorporated. 

It  is  in  exact  parallel  with  the  facts  in  physiology  which  I  then  ad- 
duced, that  in  certain  general  diseases  of  the  blood,  organs  are  formed, 
as  the  products  of  inflammation,  within  which  the  specific  morbid  mate- 
rial is  incorporated.     Thus,  in  small-pox,  cow-pox,  primary   syphilis, 

*  The  experiments  by  Cl.  Bernard  and  others,  alhided  to  on  p.  5"2,  conchisively  show 
that  great  hypersemia  and  increased  redness  and  temperature  may  occur  in  a  part,  under 
certain  conditions,  without  being  accompanied  by  any  of  the  other  evidences  of  inflamma- 
tion. 


302  NATURE    AND     CAUSES    OF    INFLAMMATION. 

and  Avhatever  other  diseases  may  be  transferred  by  inoculation,  the 
morbid  material  from  the  blood  is  incorporated  in  the  products  of  inflam- 
mation, which  are  inclosed  within  the  characteristic  vesicle  or  pustule, 
or  infiltrated  lymph,  just  as,  in  the  cases  already  cited,  the  constituents 
of  urine  or  of  medicines  are  incorporated  in  the  renal  cells,  which  are 
formed  within  the  substance  of  the  kidney  ;  or  just  as  the  constituents 
of  sap  are  incorporated  in  fruit. 

In  the  cases  of  disease  produced  by  a  demonstrable  virus,  we  have 
all  the  evidence  that  can  be  necessary  to  prove  the  principle,  that  a 
general  disease  of  the  blood  may  be  the  cause  of  a  local  inflammation 
in  one  or  more  circumscribed  portions  of  a  tissue.  And  the  analogy  is 
so  close,  that  I  think  we  need  not  hesitate  to  receive  the  same  explana- 
tion of  other  inflammations,  which  I  have  cited  as  occurring  during  mor- 
bid conditions  of  the  blood.  For  although  we  cannot,  by  inoculation, 
prove  that  a  specific  morbid  material  of  such  a  disease  as  herpes  or 
eczema,  gout  or  rheumatism,  has  been  incorporated  in  the  inflammatory 
products,  yet  we  find  great  probability  hereof  in  the  many  analogies 
which  these  diseases  present  to  the  inoculable  diseases,  in  their  whole 
history,  and,  especially,  in  the  decrease  or  modification  of  general  illness 
which  ensues  on  the  full  manifestation  of  the  local  inflammation. 

If  it  be  asked  why  a  morbid  material  is  determined  to  one  part  or 
tissue  rather  than  another,  or  why,  for  example,  the  skin  is  the  normal 
seat  of  inflammation  in  small-pox,  the  joints  in  rheumatism,  and  so  on, 
I  believe  Ave  must  say  that  we  are,  on  this  point,  in  the  same  ignorance 
as  we  are  concerning  the  reason  why  the  materials  of  sweat  are  dis- 
charged at  the  skin,  those  of  urine  at  the  kidneys,  of  bile  at  the  liver, 
or  why  the  greater  part  of  the  albuminous  principles  are  incorporated 
in  the  muscles,  and  of  the  gelatinous  in  the  bones.  We  cannot  tell  why 
these  things  are  so,  but  they  are  familiar  facts,  and  parallel  with  what 
I  here  assume  of  the  incorporation  of  morbid  materials  derived  from 
the  blood. 

Again,  it  may  be  said  that  we  need  some  explanation  of  the  fact  that 
the  morbid  condition  of  the  blood  does  not  influence  the  whole  extent 
of  any  given  tissue,  but  only  portions  of  it.  In  the  secretion  of  urine, 
it  may  be  believed  that  the  whole  kidney  is  aff'ected  and  works  alike  ; 
but  in  the  assumed  separation  of  the  virus  of  small-pox,  only  patches 
of  the  skin  are  the  seats  of  pustules  ;  in  vaccinia  and  primary  syphilis, 
only  a  single  point ;  in  secondary  and  tertiary  syphilis,  a  certain,  but 
sometimes  disorderly,  succession  of  various  parts  ;  and  so  on. 

It  must  be  admitted  that  many  of  the  facts  here  referred  to  cannot 
yet  be  explained.  In  some  cases,  however,  we  can  assign,  with  much 
probability,  the  conditions  that  determine  the  locality  in  which  a  general 
disease  of  the  blood  will  manifest  itself  by  inflammation.  In  some  in- 
stances, it  is  evident  that  the  localization  is  determined  by  such  as  we 
may  call  a  weakened  or  depressed  condition,  a  state  of  already  impaired 
nutrition,  in  some  one  part.     For  instance,  when  a  stream  of  cold  air 


NATURE    AND    CAUSES    OF    INFLAMMATION.  303 

is  impelled  on  some  part,  say  the  shoulder,  of  a  person  disposed  to  rheu- 
matism, it  determines,  as  a  more  general  exposure  to  cold  might  do  in 
the  same  person,  the  rheumatic  state  of  the  blood  with  all  its  general 
symptoms :  but  it  determines,  besides,  the  part  in  which  that  rheumatic 
state  shall  manifest  itself  first  or  alone.  The  depressed  nutrition  of  the 
chilled  shoulder  makes  it  more  liable  than  any  other  part  to  be  the  seat 
of  inflammation  excited  by  the  diseased  blood. 

Or,  again,  when  a  virus  is  inserted,  as  in  all  cases  of  poisoned  wounds, 
the  local  inflammation  produced  by  the  disease  with  which  the  whole 
blood  is  infected  will  commonly  have  its  seat  in  the  wounded  part. 
The  virus  must  have  produced  some  change  in  the  place  in  which  it 
was  inserted,  as  well  as  in  the  whole  mass  of  the  blood.  The  change 
is  not  merely  that  of  a  wound  ;  for  a  simple  wound  made  in  the  same 
person,  at  the  same  time,  will  not  similarly  inflame  ;  it  is  a  change  due 
to  the  direct  influence  of  the  virus.  And  the  part  thus  changed  may 
long  remain  in  a  peculiar  morbid  state,  and  peculiarly  prone  to  inflam- 
mation from  diseased  blood.  Thus,  an  infant  was  vaccinated  in  the 
middle  of  June,  and  the  disease  had  its  usual  course  ;  six  ordinary  vesi- 
cles formed  in  the  punctures  in  the  left  arm,  and  common  cicatrices  re- 
mained, and  all  appeared  well.  In  the  middle  of  July,  inflammation  of 
the  left  axillary  glands  ensued.  When  I  saw  the  child  on  August  21st, 
the  glands  were  very  large,  and  partially  suppurated,  and  there  was 
extensive  inflammation  of  the  skin  of  the  upper  arm.  On  August  30th, 
the  pus  having  been  partially  discharged  by  incision,  the  glands  had 
subsided,  but  superficial  inflammation  of  the  integuments  existed  still, 
and  now  there  was,  on  the  middle  of  each  vaccine  cicatrix,  a  distinct 
circular  low  vesicle,  not  unlike  that  of  the  true  vaccine  eruption,  ex- 
cept that  it  was  not  umbilicated,  and  appeared  to  have  an  undivided 
cavity. 

Such  cases  are,  probably,  only  examples  of  a  general  rule,  that  a 
part  whose  natural  force  of  nutrition  is  in  any  way  depressed,  is,  more 
than  a  healthy  part,  liable  to  become  the  seat  of  chief  manifestation  of 
a  general  blood-disease.  A  part  that  has  been  the  seat  of  former  dis- 
ease or  injury,  and  that  has  never  recovered  its  vigor  of  nutrition,  is 
always  so  liable  ;  it  is  a  weak  jjart.  Thus,  the  old  gouty  or  rheumatic 
joint  is  apt  to  receive  the  brunt  of  the  new  attack.  And  the  same  may 
happen  in  a  more  general  way.  A  man  was  under  my  care  with  chronic 
inflammation  of  the  synovial  membrane  of  his  knee,  and  general  swell- 
ing about  it ;  he  was  attacked  with  measles,  and  the  eruption  over  the 
diseased  knee  was  a  diflused  bright  scarlet  rash.  A  patient  under  Dr. 
Budd's  care  had  small-pox  soon  after  a  fall  on  the  nates  :  the  pustules 
were  thinly  scattered  everywhere,  except  in  the  seat  of  former  injury, 
and  on  this  they  were  crowded  as  thickly  as  possible.  Thus,  too,  when 
a  part  has  been  injured,  and,  it  may  be,  is  healing,  a  disease  having 
begun  in  the  blood  will  manifest  itself  in  this  part.     Impetigo  appears 


304  NATURE    AND    CAUSES    OF    INFLAMMATION. 

about  blows  and  scratches  in  unhealthy  children  ;  erysipelas  adout  the 
same  in  men  with  unhealthy  blood. 

Such  are  some  of  the  cases  in  which  we  seem  able  to  explain  the  ap- 
parent choice  of  locality  for  inflammation,  made  by  a  morbid  material 
which  is  difi"used  through  all  the  blood.  Many  remain  unexplained ; 
if  it  were  not  so,  this  portion  of  pathology  would  be  a  singular  excep- 
tion to  the  general  condition  of  the  science.  But  these  difficulties 
afford  no  warrant  for  the  rejection  of  a  theory,  of  which  the  general 
probability  is  affirmed  by  so  many  analogies,  by  the  sufficiency  of  its 
terms  for  the  expression  of  the  facts,  and,  it  may  be  added,  by  nearly 
every  particular  in  the  constitutional  treatment  of  local  inflammation. 
For,  I  suppose  there  are  few  parts  of  the  medicinal  treatment  of  local 
inflammation,  for  which  any  reason  can  be  shown,  unless  it  be  assumed 
that  the  medicine  corrects  some  morbid  condition  of  the  blood. 

Let  it  be  added  that  the  state  of  the  blood  may,  in  part,  or  chiefly 
determine,  not  only  the  locality,  but  also  the  degree  and  form  of  the 
inflammation.  It  may,  as  Dr.  Ormerod  has  well  expressed  it,  "  imprint 
on  the  morbid  product  (of  inflammation)  certain  tendencies  which  take 
effect  after  the  morbid  products  have  entered  upon  a  condition  of  com- 
paratively independent  existence."*  But  on  this  point  I  need  not  dwell ; 
for  a  large  portion  of  Lecture  XIV  is  devoted  to  it,  and  it  will  be  again 
considered  in  the  Lecture  on  Specific  Diseases. 

III.  To  test  the  influence  of  a'  disturbance  of  the  nervous  force  in 
engendering  the  inflammatory  process,  we  must  not,  as  is  commonly 
done,  take  cases  of  the  effects  of  external  injury.  Such  an  injury,  or 
the  presence  of  a  foreign  body,  is  supposed  to  excite  inflammation  by 
stimulating  the  nerves  of  the  part,  and  by  changing,  through  their  influ- 
ence, the  state  or  action  of  the  bloodvessels.  This  may  be  true  ;  but  we 
should  remember  that  when  a  common  injury  is  inflicted,  it  acts  not  only 
on  the  nerves  of  the  part,  but  also  on  its  proper  tissues  ;  and  it  may 
so  affect  the  state  of  these  tissues  that  the  changes  produced  in  them 
may  be  the  excitant  of  inflammation,  independent  of  the  affection  of  the 
nerves.     All  such  cases  as  these  are,  thus,  ambiguous. 

For  a  better  test,  we  must  select  cases  in  which  the  excitant  of  in- 
flammation acts  (at  least  in  the  first  instance)  on  the  nervous  system 
alone.  Such  cases  are  those  already  referred  to  (p.  225).  When  the 
conjunctiva  is  inflamed  after  overworking  of  the  eye,  we  cannot  sup- 
pose that  the  light,  by  its  direct  contact,  has  affected  the  vessels,  or  the 
nutritive  act,  in  the  conjunctiva :  it  can,  probably,  affect  either  of  these 
only  through  an  influence  reflected  from  the  retina.  So,  when  irritation 
of  the  urethra  excites  inflammation  in  the  testicle ;  when  the  irritation 
of  teething  excites  it  in  any  distant  part ;  when,  as  in  a  case  quoted 
from  Lallemand,  by  Dr.  Williams,  inflammation  of  the  brain  followed 

*  In  his  lectures  on  the  Pathology  and  treatment  of  Valvular  Disease  of  the  Heart,  in  the 
Medical  Gazette,  1851. 


NATURE    AND     CAUSES     OF    INFLAMMATION.  305 

the  application  of  a  ligature  to  part  of  the  brachial  plexus ;  in  these 
and  the  like  cases  we  cannot  but  refer  to  the  disturbance  of  the  nervous 
force  as  the  initiator  of  the  phenomena  of  inflammation. 

Now,  for  the  explanation  of  such  cases  as  these,  there  appear  to  be 
two  chief  theories:  1.  It  may  be  that  the  nerves  distributed  to  the 
minute  bloodvessels  of  a  part  may  be  so  afi"ected  that  these  vessels  may 
dilate,  and  their  dilatation  may  produce  the  other  phenomena  of  inflam- 
mation ;  or,  2.  The  disturbance  of  the  nervous  force  may  more  directly 
interfere  with  the  process  of  nutrition,  inasmuch  as  this  force  exercises 
always  some  influence  in  the  nutrition  of  each  part,  and  is  (as  one  may 
say)  among  the  plasturgic  forces  (p.  48). 

The  first  of  these  theories  has  lately  acquired  a  dominant  place  in 
systems  of  pathology,  especially  in  those  of  Germany.  The  principal 
form  of  it,  which  has  been  maintained  most  prominently  by  Henle,  has 
enlisted  the  approval  of  even  Rokitansky,  and  is  largely  received,  pro- 
fessing to  explain  all  inflammations,  and  passing  by  the  name  of 
"neuro-pathological,"  to  distinguish  it  from  the  "  humoral,"  and  all 
other  theories  of  inflammation.  This  theory  may  be  thus  briefly  stated. 
The  exciting  cause  of  inflammation,  whether  an  external  cause,  such  as 
an  injury  of  a  part,  or  an  internal  one,  such  as  diseased  blood,  acts,  in 
the  first  instance,  on  the  sensitive,  centripetal,  or  aff"erent  nerves  of  the 
part.  These  it  afi'ects  as  a  stimulant,  producing  in  them  an  excited 
state,  which  state,  being  conveyed  to  some  nervous  centre,  is  thence 
reflected  on  the  centrifugal  or  motor  nerves  of  the  bloodvessels  of  the 
same,  or  some  other  related  part.  This  reflection,  however,  is  supposed 
to  bring  about  a  kind  of  antagonistic  sympathy,  such  that,  instead  of 
exciting  the  motor  forces  of  the  bloodvessels  to  make  them  contract,  it 
paralyzes  them,  and  is  followed  by  their  dilatation  or  relaxation.  This 
dilatation  being  established,  the  exudation  and  other  phenomena  of  in- 
flammation are  assumed  to  follow  as  natural,  and  most  of  them  as 
mechanical,  consequences. 

The  eminence  of  those  who  have  supported  this  hypothesis  makes 
one  hesitate  in  rejecting  it ;  and  yet  I  cannot  help  believing  it  to  be 
groundless.  If  we  remember  that  parts  may  present  some  of  the  chief 
phenomena  of  inflammation,  though  they  have  no  nerves,  as  the  flrmest 
tendons  and  articular  cartilages  ;  that  the  degrees  of  inflammation  in 
parts  bear  no  proportion  to  the  amounts  of  pain  in  them  when  inflamed ; 
that  the  severest  pains  may  endure  for  very  long  periods  with  only 
trivial,  if  any,  phenomena  of  inflammation  ;  that  the  phenomena  "of  the 
so-called  reflex  paralysis  are  rare,  equivocal,  and  altogether  insufiicient 
for  the  foundation  of  a  law  or  general  principle ;  we  may  well  think 
that  there  can  be  no  sufficient  ground  for  the  invention  of  such  an 
hypothesis  as  this.  And,  if  we  add  that,  even  admitting  the  dilatation 
of  bloodvessels  as  a  possible  consequence  of  the  stimulus  of  sensitive 
nerves,  yet  the  phenomena  of  even  simple  inflammation  would  be  no 
necessary  consequence    thereof;    that  the  varieties  of  inflammations 


306  NATURE    AND    CAUSES    OF    INFLAMMATION. 

would  be  quite  unintelligible  as  results  of  similar  mechanical  disturb- 
ances of  the  circulation  ;  and  that  the  dilatation  of  bloodvessels,  in  any 
mechanical  way  produced,  is  followed  by  only  feeble  imitations  of  a 
part  of  the  inflammatory  process ;  then  we  may  think  that  the  hypo- 
thesis, if  all  its  postulates  be  granted,  will  yet  be  insufficient  for  the 
explanation  of  the  facts. 

I  believe  that,  if  we  would  have  any  clear  thoughts  respecting  the 
influence  of  the  nerves  in  initiating  inflammations,  we  must  first  receive 
the  theory  already  referred  to  (p.  48  and  p.  224),  that  a  certain  exer- 
cise of  the  nervous  force  is  habitually  and  directly  engaged  in  the  act 
of  normal  nutrition.  If  we  admit  this,  there  can  be  little  difficulty  in 
believing,  whatever  there  may  be  in  explaining,  that  the  perturbations 
of  the  nervous  force  may  engender  the  inflammatory  mode  of  nutrition 
more  directly,  than  by  first  paralyzing  the  bloodvessels  of  a  part.  We 
attain  nearly  to  a  proof  of  this  in  the  instances  of  altered  nutrition 
adduced  in  a  former  lecture  (p.  49),  and  in  those  of  secretions  altered, 
not  in  quantity  alone,  but  in  'quality,  by  affections  of  the  nervous 
system.  '  It  is  almost  inconceivable  that  any  of  the  essential  properties 
of  a  secretion  should  be  changed  by  an  alteration  in  the  quantity  or 
movement  of  the  blood  in  a  gland :  yet  such  changes  are  frequently 
manifest  in  the  milk,  tears,  urine,  and  sweat,  under  the  influence  of 
mental  aff'ections  of  the  nervous  force ;  and  the  analogies  of  secretion 
and  nutrition  give  these  cases  nearly  the  weight  of  proof  in  the  ques- 
tion of  the  influence  of  the  disturbed  nervous  force  in  causing  inflam- 
mations. 

ly.  The  last  of  the  necessary  conditions  of  normal  nutrition  in  a 
part  is  the  healthy  state  of  the  part  itself;  and  it  appears  highly  pro- 
bable that  a  disturbance  of  this  may  initiate,  and,  in  this  sense,  be  the 
cause  of  inflammation.  This  is  probably  for  many  reasons  ;  and,  first, 
from  analogy  with  normal  nutrition.  Generally,  the  principal  condi- 
tions of  nutrition  are  in  the  relative  and  mutual  influences  of  the 
elements  of  the  tissues  and  the  blood.  More  particularly,  the  state  of 
the  tissues  determines,  at  least  in  great  measure,  both  the  quantity  and 
the  rate  of  movement  of  the  blood  supplied  to  them ;  the  changes  of 
the  tissues,  whether  in  growth  or  decrease,  usually  just  preceding  the 
adapted  changes  in  the  supply  of  blood  (p.  67).  So,  we  may  believe,  a 
change  in  a  part,  anyhow  engendered,  may,  by  altering  its  relation  to 
the  blood,  alter  its  mode  of  nutrition,  and  some  of  the  changes  may 
produce  the  inflammatory  mode  of  nutrition,  together  with  the  altered 
supply  of  blood,  and  other  characteristic  signs.*  I  am  disposed  to 
think  such  changes  would  be  especially  effective,  as  causes  of  inflamma- 
tion, when  they  ensue  in  the  rudimental  and  still  developing  elements 
of  the  tissue ;  for,  as  it  seems  to  be  chiefly  these  which  determine  the 

*  See  as  confirming  this  statement  the  observations  of  Prof.  Lister,  quoted  in  the  notes  to 
pp.  223,  227. 


NATURE    AND     CAUSES    OF    INFLAMMATION.  307 

normal  supply  of  blood  in  a  part,  so,  probably,  the  abnormal  state  of 
them  would  most  affect  that  supply. 

Secondly,  we  may  judge  the  same  from  the  analogy  between  inflam- 
mation and  the  process  of  repair.  Certainly  it  is  the  state  of  the 
injured  part,  i.  e.  of  its  proper  tissues,  not  of  its  nerves  and  blood- 
vessels, which  initiates  the  processes  of  repair.  Now,  some  of  these 
are  so  like  those  of  inflammation,  that  they  are  commonly  identified, 
and  are  not  capable  of  even  a  refined  distinction.  This  is  especially 
the  case  with  the  articular  cartilages,  and  the  cornea.* 

And  thirdly,  the  influence  of  the  condition  of  the  proper  tissues  of  a 
part  in  initiating  inflammation  in  it,  is  illustrated  by  more  direct  facts ; 
such  as,  that  injuries  of  parts  that  have  no  vessels  or  nerves  are  fol- 
lowed by  altered  modes  of  nutrition  which  are  more  or  less  exact 
resemblances  of  inflammation.  Thus,  e.  g.  it  is  in  the  lens,  vitreous 
humor,  and  the  like,  after  injury.  In  all  of  these,  it  is  difficult  to  ima- 
gine any  other  cause  of  inflammation  than  the  altered  relations  between 
the  tissue  and  the  blood  or  the  materials  derived  from  it. 

On  the  whole,  therefore,  I  think  we  may  conclude  that  inflammation 
may  have  its  origin  in  disturbance  of  the  normal  condition  of  the  pro- 
per tissues  of  a  part ;  in  such  a  disturbance  as  may  be  produced  by 
injury,  or  by  the  proximity  of  disease.  To  this  source,  indeed,  I  should 
be  disposed  to  refer  nearly  all  inflammations  that  originate  in  the  direct 
application  of  local  stimuli,  whether  mechanical  or  chemical.  It  is  true, 
that,  in  most  cases,  the  stimulus  affects  at  once  the  proper  elements  of 
the  part,  its  nerves,  and  its  bloodvessels,  so  that  we  cannot  say  how 
much  of  the  disease  is  to  be  ascribed  to  the  affection  of  each;  but  the 
fact  that  a  process,  resembling,  so  far  as  it  goes,  that  of  inflammation, 
may  ensue  after  injury  in  parts  that  have  neither  vessels  nor  nerves, 
may  make  one  believe  that,  in  parts  that  have  both,  the  inflammation 
depends  mainly  on  injury,  or  other  affection,  of  the  proper  tissue. 

I  have  thus  endeavored  to  show  that  inflammation  may  take  its  rise, 
may  have  its  proximate  cause,  in  a  disturbance  of  any  one  of  the  con- 
ditions of  nutrition.  In  the  examination  of  different  cases,  we  find 
that,  even  while  any  three  of  the  four  chief  conditions  may  be  normal, 
yet  a  qualitative  error  of  the  fourth  may  bring  in  the  phenomena  of  the 
inflammatory  process.  In  the  necessity  of  choosing  pointed  cases,  I 
may  seem  to  have  implied  that  it  is  usual  for  inflammation  not  only  to 
begin,  but  to  be  maintained,  by  an  error  in  one  of  the  conditions  of 
nutrition  :  but  this  is  improbable.     Rather  we  may  believe,  that  many 

*  See  Dr.  Redfern's  Researches,  1.  c.  ;  and  compare  Mr.  Bowman's  account  of  the  heal- 
ing of  wounds  in  the  cornea,  in  his  Lectures  on  the  Parts  concerned  in  Operations  on  the 
Eye,  p.  29,  with  the  observations  already  quoted  from  Virchow.  The  doctrine  of  the  Cel- 
lular Pathology  as  illustrated  by  Virchow  is  based  exclusively  on  the  state  of  the  tissues. 
The  action  of  irritants  on  a  part  being  ascribed  to  the  effects  produced  by  them  upon  the 
elements  of  the  tissues  directly,  and  not  through  the  nerves  or  bloodvessels. 


308  NATUEE    AND    CAUSES    OF    INFLAMMATION. 

of  the  excitants  of  inflammation  may  aifect  at  once  more  than  one  of 
these  conditions ;  and,  as  I  stated  in  the  first  lecture  on  the  subject,  it 
is  nearly  certain  that  in  every  inflammation,  after  a  short  continuance, 
all  the  conditions  of  the  nutritive  process  are  alike  involved  in  error. 

The  following  are  references  to  some  of  the  recent  essays  on  inflammation,  from  which 
the  reader,  if  he  have  learned  the  main  principles  concerning  the  disease  from  some  of  the 
classical  works  upon  it, — such  as  those  of  Hunter,  Thomson,  Alison,  or  Gendrin, — may 
gather  the  best  facts  and  guidance  for  future  inquiry. 

J.  Hughes  Bennett:  On  Inflammation  as  an  Anormal  Process  of  Nutrition.     Edinburgh, 

1844. — Lectures  on  Clinical  Medicine,  3d  ed.  1859. 
Bruecke  (as  quoted  by  Lebert) :  Bemerkungen  iiber  Entziindung ;  in  the  Sitzungsberichte 

der  Wiener  Akademie.     June  and  July,  1849. 
Carpenter:  In  an  article  in   the  British  and  Foreign  Medical  Review,  vol.  xviii,  p.  91. 

July,  1844. 
Andrew  Clark:  In  the  Medical  Gazette,  vol.  xlii,  p.  286;  and  in  subsequent  numbers. 
Gluge  :  Pathologische  Histologic,  4to.     Jena.    1850. 

Henle :  Rationelle  Pathologic,  B.  i.     And  in  his  Zeitschrift,  especially  the  ■2d  volume. 
G.  M.Humphry;  Lectures  on  Surgery;  in  the  Provincial  Medical  and  Surgical  Journal, 

1849,  and  following  years. 

Wharton  Jones :  On  the  State  of  the  Blood  and  Bloodvessels  in  Inflammation ;  in  Guy's 

Hospital  Reports,  vol.  vii.     1851. 
Kiiss  (as  often  quoted  by  Lebert  and  Virchow)  :  De  la  Vascularity  et  de  llnflammation. 

1846. 
Lebert :  Physiologic  Pathologique. 
Redfern  :  Anormal  Nutrition  in  Articular  Cartilages.     Edinburgh,  1850.     And  especially, 

in  an  Appendix  to  a  Paper  in  the  Monthly  Journal  of  Medical  Science,  Sept.  1851. 
Reinhardt :  Ueber  die  Genesis  der  niikrosk.    Elements  in  den   Entziindungsproducten ; 

in  Traube's  Beitrage,  H.  li,  1846. 
Rokitansky  :  Pathologische  Anatomic,  B.  i. 
Simon:  Lectures  on  General  Pathology.   In  the  Lancet,  1850:  and,  collected,  8  vo.  London, 

1850.  Article  Inflammation  in  Holmes's  System  of  Surgery.   1860. 
Travers  :  Physiology  of  Inflammation  and  the  Healing  Process,  8vo.     1844. 

Virchow:  Essays  in  the  1st  and  3d,  and  especially  in  the  4th  volumes  of  his  Archiv  fiir 
Pathologische  Anatomic.  And  in  the  1st  volume  of  the  Verhandlungen  der  phys.-med. 
Gesellschaft  in  Wiirzburg.     Cellular  Pathologic,  1858. 

H.  Weber  :  Experimente  iiber  die  Stase  in  der  Froschschwimmhaut,  in  Miiller's  Archiv,  H. 
iv,   1852. 

C.J.  B.Williams:  Principles- of  Medicine,  8vo.      1843andl848. 

Lister:  Philos.  Trans.,  part  2,  1858.     On  the  Early  Stages  of  Inflammation. 

Billroth  :  Beitrage  zur  Path.  Histologie.    1858.  Berlin. 

C.O.Weber:  Die  Entwicklung  des  Eiters.     Virchow's  Archiv.     1859. 

The  process  of  inflammation,  so  far  as  it  can  be  illustrated  by  specimens,  may  be  fully 
studied  in  the  Museum  of  the  College,  in  the  preparations  Nos.  71  to  129,  and  in  those  which 
are  referred  to  after  the  descriptions  of  these  in  the  1st  volume  of  the  Pathological  Catalogue. 
Many  of  the  facts  relating  to  the  state  of  the  bloodvessels,  also,  are  illustrated  by  the  micro- 
scopic specimens  in  the  same  Museum.  All  the  best  illustrations  of  the  process,  in  the  Mu- 
seum of  St.  Bartholomew's,  may  be  studied  by  the  references  in  the  Catalogue,  vol.  i,  p.  xii. 


MORTIFICATION.  309 

LECTURE    XIX. 

'  MORTIFICATION. 

By  Mortification,  or  Sphacelus,  is  meant  the  death  of  any  portion  of 
the  body,  while  the  rest  remains  living.  The  term  "  gangrene"  is  com- 
monly used  in  the  same  sense;  "necrosis"  for  similar  death  of  portions 
of  bone  or  cartilage,  or,  in  some  recent  writers,  of  any  other  tissue ; 
"  necrsemia"  for  a  corresponding  death  of  the  blood.  The  dead  piece 
of  tissue  is  called  a  "slough,"  or,  if  it  be  bone,  a  "  sequestrum."  The 
process  of  progressive  dying  is  commonly  called  "  sloughing,"  a  term 
which^  is,  however,  also  applied  to  the  process  by  which  a  slough  is 
separated,  with  the  same  meaning  as  "exfoliation"  is  used  for  the  pro- 
cess of  separating  a  "sequestrum"  or  dead  piece  of  bone.  None  of 
these  terms,  however,  are  used  unless  the  portions  of  dead  tissue  be  visi- 
ble to  the  naked  eye.  It  is  probable  that  what  is  ejected  from  the  tis- 
sues in  the  ulcerative  process  is  quite  dead  ;  but,  so  long  as  it  is  in  the 
form  of  minute  particles,  visible  only  with  the  microscope,  we  speak  of 
the  disease  as  ulceration,  not  sloughing  or  mortification.  The  two  pro- 
cesses are,  however,  often  mingled,  and  can  be  only  in  general  terms, 
and  in  well-marked  examples,  distinguished. 

It  might,  also,  be  difficult  to  define,  in  precise  terms,  this  death  of 
parts  from  some  examples  of  their  degeneration.  We  may  doubt,  some- 
times, whether  the  degenerative  changes,  imitated,  as  certain  of  them 
are,  by  chemical  changes  in  the  tissues  after  death,  are  not  consequences 
of  the  total  cessation  of  the  influence  of  vital  forces  ;  and  it  seems  nearly 
certain  that  degeneration  of  a  part  may  proceed  to  its  death,  and  is 
very  apt  to  do  so  when,  during  its  progress,  many  of  the  conditions  of 
nutrition  are  at  once  interfered  with.  In  a  general  view  we  may  dis- 
tinguish the  degeneration  of  a  part  from  its  death  by  this, — that  the 
degenerate  part  never  becomes  putrid,  and  that  no  process,  ensues  for  its 
separation  or  isolation,  such  as  we  can  see  in  the  case  of  a  dead  part. 
However  degenerate  a  tissue  may  be,  it  either  remains  in  continuity 
with  those  around  it,  or  is  absorbed.  If  the  same  tissue  were  dead, 
those  around  it  would  separate  from  it,  and  it  would  be  ejected  from 
them. 

Still,  it  may  not  be  pretended  that  degeneration  and  death  are  sepa- 
rated by  a  strong  border-line.  Rather,  many  of  the  instances  of  mor- 
tification to  which  I  am  about  to  refer  may  be  read  as  histories  of  the 
transition  from  one  of  these  conditions  to  the  other.  It  will  appear 
that  a  part  may  degenerate  even  to  death  while  the  rest  of  the  body 
remains  alive ;  that,  as  a  certain  diminution  of  the  supply  of  arterial 
blood  may  lead  to  degeneration,  so  a  greater  diminution  may  lead  to 
death ;  that,  as  a  certain  amount  of  inflammation  has  always  in  it  a 


310  CAUSES    OF    MORTIFICATION. 

defective  nutrition  of  the  inflamed  part,  so,  in  a  greater  amount,  the 
death  of  the  same  part  ensues  ;  and  that  the  same  agent  may  kill  one 
portion  of  a  tissue  and  inflame  the  portions  around  it.  Of  all  such 
cases  we  might  say  that  the  local  death  is  the  extreme  of  degeneration. 

A  convenient  method  of  studying  the  causes  of  mortification  may  be 
to  divide  those  among  them  that  are  explicable  into  the  direct  and  the 
indirect ;  i.  e.  into  such  as  disorganize  and  kill  the  tissues  at  once,  and 
directly,  though  sometimes  slowly,  and  such  as  do  so  indirectly,  by  de- 
priving them  of  some  or  all  of  the  conditions  of  their  nutrition.  Such 
a  division,  however,  must  not  lead  us  to  forget  that,  in  many  cases,  mor- 
tification is  the  result  of  many  concurring  causes  of  both  kinds. 

L  In  the  first  class  we  may  reckon  the  mortifications  that  are  the 
extremes  of  degeneration.  But  these  can  rarely  be  observed  in  un- 
mixed examples.  The  more  evident  instances  are  those  which  result 
from  great  heat,  rapidly  decomposing  chemical  agents,  and  severe  me- 
chanical injury.  The  appearances  of  the  dead  tissues  are,  in  these 
cases,  modified  by  the  presence  of  blood  in  those  that  are  vascular,  and 
by  the  blood  being  killed  in  and  with  them :  but  the  state  of  the  blood 
is  no  cause  of  their  death ;  the  tissues  and  the  contained  blood  are  killed 
together ;  and  the  same  mode  and  consequences  of  mortification  would 
be  manifested  in  the  non-vascular  tissues. 

Now,  as  I  just  suggested,  it  may  be  observed  of  all  these  destructive 
agents,  that  when  they  are  applied  in  smaller  measure,  the  effect  of  the 
injury  is  not  to  kill  the  part  at  once,  but  to  excite  an  inflammation  in 
it ;  and  the  inflammatory  degeneration,  thus  added  to  the  damage  the 
part  sustained  from  the  direct  efi"ect  of  the  injury,  may  lead  to  an  indi- 
rect or  secondary  mortification.  To  this  mixed  origin,  probably,  many 
of  the  cases  of  traumatic  gangrene  may  be  ascribed,  which  are  not 
manifest  very  speedily  after  the  injury ;  in  these  we  may  say  that  a 
severe  injury  has  so  nearly  disorganized  a  part,  that  the  subsequent  in- 
flammation, with  the  concurrent  defective  nutrition,  has  completed  its 
death.  But,  mechanical  violence,  heat,  or  chemical  action,  may  kill  a 
tissue  at  once,  without  the  intervention  of  inflammation,  and  although, 
in  the  case  of  the  vascular  tissues,  it  is  scarcely  possible  to  separate  the 
influence  of  the  injury  on  their  proper  elements,  from  that  which  is,  at 
the  same  time,  inflicted  on  their  blood  and  vessels,  yet  we  must  consider 
the  phenomena  of  mortification  as  having  their  seat,  essentially,  in  the 
elements  of  the  tissues.  Whatever  we  understand  as  the  life  of  a  part, 
that  life  may  cease  ;  and  as  the  life  of  a  part  is  its  own  property,  main- 
tained, indeed,  by  the  blood  and  other  conditions  of  nutrition,  yet  not 
derived  from  them,  so  may  that  life  cease,  or,  as  it  is  said,  be  destroyed, 
without  interference  of  the  blood  or  any  other  exterior  conditions  of 
nutrition. 

The  immediateness  of  such  death  of  a  part  is  shown  by  the  rapidity 
with  which  it  is  manifested.     It  is  nearly  instantaneous  on  the  applica- 


CAUSES    OF    MORTIFICATION.  311 

tion  of  extreme  heat  or  the  strongest  mechanical  agents ;  slower  after 
mechanical  injury  :  but  within  twelve  hours  of  the  infliction  of  a  blow 
the  struck  or  crushed  part  may  be  evidently  dead ;  there  may  be  little 
or  no  ecchymosis,  no  sign  of  inflammation,  no  pain,  except  that  which 
directly  followed  the  injury,  and,  in  the  case  of  a  bone,  no  apparent 
change  of  texture ;  but  the  piece  of  tissue  is  killed  in  the  midst  of  the 
living  parts ;  its  recovery,  by  the  re-establishment  of  its  relations  with 
the  blood,  is  not  possible :  it  cannot  even  be  absorbed. 

II.  Among  the  instances  of  indirect  mortification  of  parts,  the  most 
numerous  are  those  in  which  nutrition  is  made  impossible  by  some  defect 
either  (1)  in  the  quantity,  or  (2),  in  the  movement,  of  the  blood. 

Defects  in  the  quantity  of  blood  have  been  already  noticed  as  leading 
to  death  of  parts  (p.  45).  The  following  are  the  chief  general  methods 
of  the  events : 

The  main  artery  of  a  part  may  be  closed  by  pressure,  or  by  some  in- 
ternal obstruction.  Thus,  sometimes,  sloughing  of  the  foot,  or  leg,  fol- 
lows ligature  of  the  femoral  artery  for  popliteal  aneurism ;  or  slqugh- 
ing  of  part  of  the  brain  may  follow  ligature  of  the  common  carotid 
artery ;  and  in  this  case  the  difference,  and  yet  the  close  relation,  be- 
tween the  death  of  a  part  and  its  degeneration,  are  well  shown  (com- 
pare p.  46  and  108).  Thus,  also,  through  equal  internal  obstruction  of 
main  arteries,  sloughing  may  follow  blows  which  crack  the  internal  and 
middle  coats,  and  let  them  fold  inwards  across  the  stream  of  blood  :* 
or,  the  blocking  of  masses  of  fibrine,  washed  from  the  left  valves  of  the 
heart,  and  arrested  in  the  iliac  or  some  other  artery  :f  or  the  closure  of 
inflamed  arteries. 

Portions  of  tissue  may  similarly  perish  when,  by  injury,  or  by  pro- 
gressive ulceration  or  absorption,  all  their  minute  bloodvessels  are  de- 
stroyed, and  their  supply  of  blood  cut  off.  Thus  necrosis  may  follow 
the  separation  of  periosteum  from  the  surface  of  a  bone ;  when  it  is 
either  violently  stripped  off,  or  raised  by  effused  blood,  or  by  suppura- 
tion beneath  it.  Thus,  also,  sometimes,  as  an  abscess  approaches  the 
surface,  the  thinned  skin  dies ;  and,  not  like  an  inflamed  part,  but  as 
one  deprived  of  nutriment,  it  shrivels  and  is  dried.  Such  sloughing  is 
more  common  in  perforating  ulcers  of  the  stomach  or  intestines  ;  in  the 
course  of  which,  when  ulceration  has  destroyed  a  portion  of  the  subperi- 
toneal tissue  and  its  bloodvessels,  the  peritoneum,  hitherto  fed  by  them, 
perishes,  and  is  separated  as  a  grayish  or  yellowish-white  slough.  In 
like  manner,  ulceration,  in  its  progress,  may  so  undermine  or  intrench 
a  part,  that  at  length  it  dies  through  defect  of  blood  :  thus,  often,  small 
fragments  of  bone  are  detached  in  strumous  disease  of  the  tarsus  and 
other  parts.  And,  similarly,  through  mere  defect  of  blood,  the  centre 
of   a  tumor  may  slough :    and    here,  again,  is    manifest  the   relation 

*  Two  such  specimens  are  in  the  Museum  of  St.  Bartholomew's. 
■f  See  Dr.  Kirkes's  essay  in  Med.-Chir.  Trans.,  vol.  xxxv. 


312  CAUSES    OF    MORTIFICATION". 

between  the  death,  and  the  more  frequent  degeneration,  of  an  imper- 
fectly nourished  part. 

The  effect  of  pressure  constantly  maintained  on  a  part  may  he  a  simi- 
larly produced  mortification:  the  part  may  die  because  its  blood  is 
pressed  from  it  and  not  renewed ;  but  more  commonly,  as  we  see  in  bed- 
sores, inflammation  ensues,  and  the  death*  of  the  part  has  a  double  or 
mixed  origin. 

Senile  gangrene,  also,  is  without  doubt,  in  many  cases,  due,  in  a 
measure,  to  defective  quantity  of  blood;  but  it  is  a  more  complicated 
example  of  mortification  than  any  of  the  foregoing,  and  I  shall  there- 
fore again  refer  to  it. 

I  have  said  that  parts  may  die  through  defective  movement  of  blood. 
It  may  be  present  in  sufficient  or  excessive  quantity ;  but  it  may  be 
fatally  stagnant.  So  far  as  the  proper  elements  of  the  tissue  are  con- 
cerned, there  may  be  little  difference  in  their  modes  of  death,  or  in  their 
subsequent  changes,  in  these  two  sets  of  cases  ;  but,  as  seen  in  the  mass, 
the  tissue  dead  through  defect  of  blood  is  very  different  from  that  dead 
through  stagnation  of  blood.  In  the  former,  we  find  little  more  than 
its  own  structures  dried  and  shrunken  or  disorganized ;  in  the  latter, 
the  materials  of  abundant  blood,  and  often  of  substances  exuded  from 
the  congested  vessels,  lie  mingled  with  the  proper  structures,  having 
died  with  them.  Hence,  mainly,  the  differences  between  the  mortifica- 
tions distinguished  as  the  dry  and  moist  gangrenes ;  or  as  the  cold  and 
hot,  the  white  and  the  black,  gangrenes ;  these  being,  respectively,  the 
technical  terms  for  parts  dead  through  defect,  or  through  stagnation, 
of  blood. 

This  stagnation  of  blood  may  ensue  in  many  ways.  The  simplest  is 
when  a  part  is  strangulated ;  as  the  contents  of  a  hernial  sac  may  be. 
If  the  strangulation  is  sudden  and  complete,  the  stagnation  is  equally 
so,  and  the  death  of  the  part  follows  very  quickly,  with  little  excess  of 
blood  in  it.  But,  if  the  strangulation  be  less  in  degree,  or  be  more 
slowly  completed,  the  veins  suffer  more  in  the  gradual  compression  than 
the  arteries  do ;  the  vessels  of  the  part  thus  become  gorged  with  blood, 
admitted  into  them  in  larger  quantity  than  it  can  leave  them,  and  so 
mortification  ensues  after  intense  congestion  or  inflammation  of  all  the 
tissues.* 

Mere  passive  congestion  of  the  vessels  of  a  part  may,  in  enfeebled 
persons,  lead  to  mortification :  but  this  is  a  rare  event,  for  unless  a 
part  be  injured,  or  of  itself  already  degenerate,  it  may  be  maintained 
by  a  very  slow  movement  of  the  blood. 

The  congestion  which  more  commonly  leads  to  mortification  is  that 
which  forms  part  of  the  inflammatory  process.  It  is,  perhaps,  to  be 
regretted  that  the  cases  of  this  class  should  have  been  taken  as  if  they 

*  This  difference  in  the  eflects  of  constrictions  of  parts  is  particularly  described  by  Sir  B. 
C.  Brodie  :  Lectures  on  Surgery  and  Pathology,  p.  304. 


CAUSES    OF    MORTIFICATION.  313 

were  the  simplest  types  of  the  process  of  mortification,  and  that  the 
process  should  have  been  studied  as  an  appendage,  a  so-called  termina- 
tion, of  inflammation :  for,  in  truth,  the  death  of  an  inflamed  part  is  a 
very  complex  matter  ;  and,  in  certain  examples  of  it,  all  the  more  simple 
causes  of  mortification  may  be  involved.  Thus  (1)  the  inflammatory 
congestion  may  end  in  stagnation  of  the  blood,  and  this,  as  an  indirect 
cause  of  mortification,  may  lead  to  the  death  of  the  blood,  and  that  of 
the  tissues  that  need  moving  blood  for  their  support.  But  (2)  a  dege- 
neration of  the  proper  textures  is  a  constant  part  of  the  inflammatory 
process ;  and  this  degeneration  may  itself  proceed  to  death,  while  it  is 
concurrent  with  defects  in  the  conditions  of  nutrition.  And  (8)  the 
exudation  of  fluid  in  some  inflamed  parts  may  so  compress,  and  by  the 
swelling  so  elongate,  the  bloodvessels,  as  to  diminish  materially  the 
influx  of  fresh  blood,  even  when  little  of  that  already  in  the  part  is 
stagnant. 

All  these,  and  perhaps  other,  conditions  may  concur  in  the  mortifica- 
tion of  an  inflamed  part ;  and  their  united  force  is  commonly  the  more 
effective,  by  being  exercised  in  a  previously  defective  or  degenerate 
condition  of  the  inflamed  tissue.  The  second  of  them,  I  think,  has 
been  too  little  considered ;  for  by  it,  more  than  by  any  other  event,  we 
may  understand  the  sloughing  that  ensues  in  the  inflamed  parts  of 
enfeebled  persons.  The  intensity  of  an  inflammation  is  not,  alone,  a 
measure  of  the  probability  of  mortification  ensuing  in  its  course ; 
neither  is  mere  debility ;  for  we  daily  see  inflammation  without,  death 
of  parts  in  the  feeblest  patients  with  phthisis  and  other  diseases :  rather, 
when  mortification  happens  in  an  inflamed  part,  it  seems  to  be  through 
the  occurrence  of  the  disease  in  those  that  have  degenerate  tissues 
because  of  old  age,  or  defective  food  or  other  materials  for  life,  or 
through  habitual  intemperance.  It  is  as  if  the  death  of  the  part  were 
the  consequence  of  the  defective  nutrition,  which  concurs  with  the  rest 
of  the  inflammatory  process,  being  superadded  to  that  previously  exist- 
ing in  the  part.  To  the  same  occurrence  we  may,  in  some  measure, 
ascribe  the  mortification  of  parts  after  comparatively  slight  injuries  in 
the  aged  and  intemperate :  already  degenerate,  they  perish,  through 
the  addition  of  what,  in  healthier  persons,  would  have  led  to  only  some 
degeneration,  or  to  the  inflammatory  process,  in  the  injured  part.  Such 
cases  as  these,  also,  stand  in  no  distant  relation  to  those  of  the  morti- 
fication that  ensues  in  inflammations  after  injuries.  And  with  these  we 
may  probably  class  the  similar  effects  of  intense  cold.  Cold  alone  does 
not,  in  general,  directly  kill  a  part,  whether  in  cold  or  in  warm-blooded 
animals :  the  death  that  ensues  appears  to  be  the  result  of  inflammation 
in  the  part  that  was  cold  or  frozen. 

Such  may  be  the  explanations  of  the  local  death  that  may  occur  in 
inflammation  ;  but,  in  many  more  cases  of  what  appear  as  mortifications 
in  inflamed  parts,  the  death  is  the  first  event  in  the  process,  and  the 
inflammation  appears  as  its  consequence ;  or  else  the  death  and  the  in- 

21 


314  CAUSES    OF    MORTIFICATION. 

flammation  are  coincident  in  different  parts  of  the  same  tissue.     To 
these  cases  I  shall  again  refer. 

In  senile  gangrene  we  commonly  find  a  very  large  number  of  condi- 
tions ministering  to  the  death  of  the  affected  part.  First,  occurring, 
as  its  name  implies,  in  the  old,  and  often  in  those  that  are  old  in  struc- 
ture rather  than  in  years,  it  affects  tissues  already  degenerate,  and  at 
the  very  extremity  and  most  feebly  nourished  part  of  the  body.  I 
think  that,  in  some  cases,  its  beginning  may  be  when  the  progressive 
degeneration  of  the  part  has  arrived  at  death.  But,  if  this  do  not 
happen,  some  injury  or  disease,  even  a  very  trivial  one,  kills  that  which 
was  already  nearly  dead;  as  a  severe  injury  might  kill  any  part,  how- 
ever actively  alive.  Now,  when  death  has  thus  commenced,  it  may  in 
the  same  manner  extend  more  widely  and  deeply,  with  little  or  no  sign 
of  attendant  disease ;  the  parts  may  successively  die,  blacken,  and  be- 
come dry  and  shrivelled;  in  this  case,  the  senile  gangrene  is  a  dry  one. 
But  more  commonly,  when  a  portion  of  a  toe  or  of  the  foot  has  thus 
died,  the  parts  ai:ound  or  within  it  become  inflamed,  and  in  these,  dege- 
nerate as  they  were  already,  the  further  degeneration  of  the  inflamma- 
tory process  is  destructive ;  and  thus,  or  in  this  extent,  by  progressive 
inflammation  and  death,  the  gangrene,  moist  though  senile,  spreads.  In 
either  case  the  extension  of  the  gangrene  is  favored  by  many  other 
things;  especially  by  the  defective  muscular  and  elastic  power,  and  by 
the  narrowing  or  obstruction  of  the  degenerate  arteries  of  the  part ;  by 
the  defective  movement  of  the  blood,  readily  inducing  a  passive  con- 
gestion or  stagnation  in  parts  of  its  course ;  by  an  enfeebled  heart ;  by 
the  blood  being,  like  the  tissues,  old,  and  doubtless,  like  them,  defective ; 
and  by  the  aptness  of  the  slow-moving  blood  to  coagulate  in  the  vessels. 
All  these  favor  the  occurrence  and  extension  of  the  senile  gangrene : 
one  or  more  of  them  may,  sometimes,  be  the  efficient  cause  of  it :  but 
my  impression  is  that  it  is  essentially,  and  in  the  first  instance,  due, 
either  to  senile  degeneration  having  reached  its  end  in  local  death,  or 
to  the  fatal  superaddition  of  an  inflammatory  degeneration  in  a  part 
already  scarcely  living. 

III.  In  the  foregoing  cases,  we  seem  able,  in  some  measure,  to  ex- 
plain the  occurrence  of  mortification.  But  there  are  yet  many  cases 
m  which  explanation,  except  in  the  most  general  and  vague  terms,  is 
far  more  difficult.  In  som€,  the  local  death  is  to  be  ascribed  to  defec- 
tive quality  of  the  blo^d,  or  to  morbid  materials  in  it.  Among  these, 
the  instances  of  sloughing  of  the  cornea  observed  in  animals,  and  more 
rarely  in  men,  whose  food  is  deficient  in  nitrogen ;  and  those  of  morti- 
fications of  the  extremities  that  have  ensued  after  eating  rye  with  ergot, 
may  prove  the  general  principle, — that  certain  parts,  even  small  and 
circumscribed  parts,  may  die  through  defects  or  errors  of  the  blood 
which  yet  do  not  quite  hinder  its  maintaining  the  rest  of  the  body. 
They  may,  thus,  be  types  of  a  large  class  of  cases,  in  all  of  which  the 
death  of  a  portion  of  tissue  seems  to  ensue  through  some  wrong  in  the 


CAUSES    OF    MORTIFICATION.  315 

blood  by  which  their  mutual  influence  is  destroyed;  of  which  cases, 
therefore,  we  may  say  that  as  there  are  morbid  conditions  of  the  whole 
blood  in  which  local  inflammations  may  have  their  origin,  so  are  there 
others  in  which  local  deaths  have  theirs. 

Boils  and  carbuncles,  for  example,  are  of  this  kind.  The  sloughs,  so 
often  separated  from  them,  are  pale  and  bloodless ;  they  are  not  por- 
tions of  tissues  that  have  died  in  consequence  of  stagnation  of  blood  in 
them  :  they  are  white  sloughs  in  the  midst  of  inflamed  parts.  In  boils, 
the  first  event  of  the  disease  may  appear  in  the  small  central  slough  ; 
in  such  cases  the  surrounding  inflammation  may  appear  to  be  the  con- 
sequence of  the  slough  ;  but,  much  more  probably,  it  is  the  result  of  a 
lesser  influence  of  the  same  morbid  condition  of  the  blood.  In  the  idio- 
pathic sloughing  of  the  subcutaneous  tissue  of  the  scrotum,  the  local 
death  is  evidently,  in  some  cases,  the  first  event  of  the  disease.  To 
this  class,  also,  of  mortifications  in  consequence  of  morbid  conditions  of 
the  blood,  we  must  refer,  I  presume,  the  cases  of  hospital  gangrene  ; 
those  of  the  most  severe  and  most  rapidly  extending  traumatic  kind  ; 
those  of  the  sloughings  of  mucous  membranes,  and  other  parts,  that 
sometimes  ensue  in  typhus,  scarlet  fever,  and  other  allied  diseases, 
when  they  deviate  from  their  ordinary  course  ;  the  sloughing  of  syphi- 
litic sores,  and  many  others. 

Lastly,  we  may  enumerate  among  the  causes  of  death  of  parts  the 
defect  of  nervous  force :  but  the  examples  of  this  have  been  related  in 
a  former  lecture  (p.  51)  ;*  and  it  only  needs,  perhaps,  to  be  said  here 
that  this  defect  may  mingle  its  influence  with  many  other  obvious  causes 
of  mortification.  When  a  part  is  severely  injured,  its  nerves  suffer  pro- 
portionate violence,  and  their  defective  force  may  add  to  the  danger  of 
mortification ;  in  the  old,  not  the  blood,  or  the  tissues  alone,  are  de- 
generate, but  the  nervous  structures  also ;  and  defective  nervous  force 
may  be,  in  them,  counted  among  the  many  conditions  favorable  to  the 
senile  gangrene  ;  and  so,  yet  more  evidently,  the  sloughing  of  com- 
pressed parts  is  peculiarly  rapid  and  severe  when  those  parts  are  de- 
prived of  nervous  force  by  injury  of  the  spinal  cord,  or  otherwise. 

While  the  causes  of  mortification  are  so  manifold ;  while  it  is,  in  fact, 
the  end  of  so  many  difl"erent  afiections,  it  is  not  strange  that  the  appear- 
ances of  the  dying  and  dead  parts  should  be  extremely  various.  The 
changes  in  them  (independent  of  those  produced  by  great  heat,  caustics, 
or  other  such  disorganizing  agents)  may  be  referred  to  three  chief 
sources  :  namely,  (1)  those  that  ensue  in  the  dying  and  dead  tissues ; 
(2)  those  in  the  blood,  dying  with  the  tissues  and  often  accumulated  in 
them  in  unnatural  abundance  ;  (3)  those  which  are  due  to  the  inflamma- 
tion or  other  disease  or  injury,  which  has  preceded  the  death  of  the 

*  There  are  yet  many  cases  which  I  can  neither  explain  nor  classify ;  such  as  those  from 
the  effects  of  animal  poisons,  malignant  pustule,  peculiar  gangrenes  of  the  skin,  and  many 
others.  On  all  these,  and,  indeed,  on  the  whole  subject  of  mortifications,  the  reader  will 
find  no  work  that  he  can  study  with  so  much  profit  as  the  lectures  of  Sir  B.  C.  Brodie. 


316  CHARACTERS    OF    MORTIFICATION. 

part,  and  of  which  the  products  die  with  the  tissue  and  the  blood,  and 
change  with  them  after  death. 

But,  though  we  may  thus  chassify  the  morbid  changes  in  mortified 
parts,  yet  we  can  hardly  enumerate  the  varieties  which,  in  each  class, 
are  due  to  the  previous  diseases  of  the  part,  or  to  external  conditions  ; 
such  as  difi"erences  of  temperature,  of  moisture,  and  others.  All  the 
chemical  changes  which,  in  life,  are  repaired  and  unobserved,  are  here 
cumulative ;  all  those  external  forces  are  now  submitted  to,  which,  while 
the  parts  were  living,  they  seemed  to  disregard  ;  so  exactly  were  they 
adjusted  in  counteraction.  It  is,  therefore,  only  in  typical  examples 
that  mortifications  can  be  well  described.  The  technical  terms  applied 
to  them  have  been  already  mentioned ;  and  "  dry"  and  "  moist"  signify 
the  chief  difierences  dependent  on  the  quantity  of  blood  and  of  inflam- 
matory products  in  the  dead  parts.  "  Dry  gangrene"  is  usually  preceded 
by  diminished  supply  of  blood  to  the  part ;  "  moist  or  humid  gangrene" 
by  increased  supply,  and  often  by  inflammation  ;  the  former  more  slowly 
progressive  is  usually  a  "chronic,"  or,  as  some  have  called  it,  "  cold 
gangrene;"  the  latter  an  "  acute  or  hot  gangrene." 

Among  the  examples  of  mortification  due  to  defective  supply  of  blood, 
and  therefore  classed  as  dry  gangrenes,  great  difl"erences  of  appearance 
are  due  to  the  degrees  in  which  the  dead  parts  can  be  dried.  As  it 
may  be  observed  in  the  integuments  of  the  leg,  for  example,  it  may  be 
noticed  that,  in  the  first  instance,  the  part  about  to  die  appears  livid,  or 
mottled  with  various  dusky  shades  of  purple,  brown,  or  indigo,  through 
which  it  seems  to  pass  as  its  colors  change  from  the  dull  ruddiness  of 
stagnant  or  tardy  blood  towards  the  blackness  of  complete  death.  It 
becomes  colder,  and  gradually  insensible  ;  its  cuticle  separates,  and  is 
raised  in  blisters  by  a  serous,  or  more  or  less  blood-colored,  or  brown- 
ish fluid.  Then,  as  the  cutick  breaks  and  is  removed,  the  subjacent 
integument,  hitherto  kept  moist,  being  now  exposed  to  the  air,  gradually 
becomes  drier ;  withering,  mummifying,  becoming  dark  brown  and  black, 
having  a  mouldy  rather  than  a  putrid  smell;  it  is  changed,  as  Roki- 
tansky  says,*  like  organic  substances  decomposed  with  insufficient  mois- 
ture and  with  separation  of  free  carbon.  Such  are  the  changes  often 
seen  in  the  dry  senile  gangrene,  and  in  that  which  may  follow  obstruc- 
tion of  the  main  arteries  in  young  persons  :  but,  very  generally,  as  the 
interior  parts  of  the  limb  cannot  be  dried  so  quickly  as  the  exterior,  and 
are,  perhaps,  less  completely  deprived  of  their  supply  of  blood,  they,  or 
portions  of  them,  become  soft  and  putrid,  while  the  integuments  become 
dry  and  musty. 

In  other  cases  of  mortification  similarly  caused,  the  dead  parts,  though 
deprived  of  blood,  cannot  become  dry  ;  either  they  are  not  exposed  to 
air,  or  they  are  soaked  with  fluid  exuded  near  them.  In  these  instances 
the  sloughs  may  be  dark ;  but  they  are  commonly  nearly  white ;  and 

*  Pathologische  Anatomie.  i,  p.  237. 


CHARACTERS     OF    MORTIFICATION.  317 

hence  one  of  the  grounds  for  the  technical  distinction  of  white  and 
black  gangrene.  Such  white  sloughs  are  commonly  seen  when  the 
peritoneum  mortifies,  after  being  deprived  of  blood  bj  ulceration  gradu- 
ally deepening  in  the  walls  of  the  digestive  canal ;  and,  sometimes,  in 
the  integuments  over  an  abscess,  when  the  cuticle  has  not  previously 
separated.  If  this  have  happened,  the  dead  and  undermined  integu- 
ment may  become  dry  and  horny;  but  if  the  cuticle  remain,  it  is  com- 
monly white,  soft,  and  putrid. 

The  typical  examples  of  the  moist  gangrene  are  those  which  occur 
in  inflamed  parts,  and  chiefly  in  consequence  of  inflammation,  and  to 
which,  therefore,  the  names  of  "  acute"  and  "  hot"  gangrene  have  been 
applied.  We  must  not  reckon  among  these  the  cases  in  which  the  death 
of  the  part  precedes,  or  has  a  common  origin  with,  the  inflammation  ; 
for  in  these,  as  in  boils,  carbuncles,  and  hospital  gangrene,  the  slough 
is  commonly  bloodless,  white  or  yellowish,  or  grayish-white,  and,  if  it 
were  not  immersed  in  fluid,  would  probably  be  dry  and  shrivelled.  The 
mortification  that  occurs  during  inflammation,  and  as  in  part  a  conse- 
quence of  it,  finds  the  tissues  full  of  blood,  and  often  of  exuded  lymph 
and  serum,  which  all  perish  with  them. 

If  such  a  process  be  watched  in  an  inflammation  involving  the  integu- 
ments, or  in  senile  gangrene  rapidly  progressive  with  inflammation,  or, 
as  in  the  most  striking  instance,  in  the  traumatic  gangrene  following  a 
severe  injury  of  a  limb,  the  parts  that  were  swollen,  full  red,  and  hot, 
and  perhaps  very  tense  and  painful,  become  mottled  with  overspread- 
ing shades  of  dusky  brown,  green,  blue,  and  black.  These  tints,  in 
mortification  after  injuries,  may,  sometimes,  seem  at  first  like  the  eff"ects 
of  ecchymoses  ;  and  often,  after  fractures  of  the  leg,  a  further  likeness 
between  the  two  is  produced  by  the  rising  of  the  cuticle  in  blisters  filled 
with  serous  or  blood-colored  fluids  at  the  most  injured  parts.  But  the 
coincident  or  quickly  following  signs  of  mortification  leave  no  doubt  of 
what  is  happening.  The  discolored  parts  become  cold  and  insensible, 
and  more  and  more  dark,  except  at  their  borders,  which  are  dusky  red  ; 
a  thin,  brownish,  stinking  fluid,  issues  from  the  exposed  integuments  ; 
gas  is  evolved  from  similar  fluids  decomposing  in  the  deeper-seated  tis- 
sues, and  its  bubbles  crepitate  as  we  press  them  ;  the  limb  retains  its 
size  or  enlarges,  but  its  tissues  are  no  longer  tense ;  they  soften  as  in 
inflammation,  but  both  more  rapidly  and  more  thoroughly,  for  they  be- 
come utterly  rotten.  At  the  borders  of  the  dying  and  dead  tissues,  if 
the  mortification  be  still  extending,  these  changes  are  gradually  lost : 
the  colors  fade  into  the  dusky  red  of  the  inflamed  but  still  living  parts  ; 
and  the  tint  of  these  parts  may  afi"ord  the  earliest  and  best  sign  of  the 
progress  towards  death,  or  the  return  to  a  more  perfect  life.  Their  be- 
coming more  dark  and  dull,  with  a  browner  red,  is  the  sure  precursor 
of  their  death ;  their  brightening  and  assuming  a  more  florid  hue,  is  as 
sure  a  sign,  that  they  are  more  actively  alive.  Doubtless  the  varieties 
of  color  indicate,  respectively,  the  stagnation  and  the  movement  of  the 


318  CHARACTERS    OF    MORTIFICATION. 

blood  in  the  parts  which,  thus  situated,  may,  according  to  the  progress 
of  their  inflammation,  be  added  to  the  dead,  or  become  the  apparatus  of 
repair.* 

The  interior  of  a  part  thus  mortified  corresponds  with  the  foregoing 
description.  All  the  softer  tissues  are,  like  the  integuments,  rotten, 
soft,  putrid,  soaked  with  serum,  and  decomposed  exuded  fluid ;  ash- 
colored,  green  or  brown ;  more  rarely  blue  or  black  ;  crackling  with 
various  gases  extricated  in  decomposition.  The  tendons  and  articular 
cartilages  in  a  mortified  limb  may  seem  but  little  changed ;  at  the  most 
they  may  be  softened,  and  deprived  of  lustre.  The  bones  appear  dry, 
bloodless,  and  often  like  such  as  have  been  macerated  and  bleached  ; 
their  periosteum  is  usually  separated  from  them,  or  may  be  easily  and 
cleanly  stripped  ofi".  But  these  harder  and  interior  parts  of  a  limb 
either  die  more  slowly,  or  more  slowly  manifest  the  signs  of  death,  than 
do  those  around  them ;  for  not  only  do  they  appear  comparatively  little 
changed,  but  often  when  all  the  dead  soft  parts  are  completely  sepa- 
rated from  the  living,  the  bone  remains  continuous, .  and  its  medullary 
vessels  bleed  when  it  is  sawn  ofi".  Usually,  also,  after  complete  spon- 
taneous separation  of  the  mortified  part  of  a  limb,  the  stump  is  conical ; 
the  outer  parts  of  it  having  died  higher  up  than  the  parts  in  its  axis. 

Another  appearance  of  mortified  parts,  characteristic  of  a  class,  is 
presented  after  they  have  been  strangulated.  I  have  mentioned  the 
difierence  which  in  these  cases  depends  on  whether  the  strangulation 
have  been  suddenly  complete,  or  have  been  gradually  made  perfect. 
In  the  former  case  the  slough  is  very  quickly  formed,  and  may  be  ash- 
colored,  gray,  or  whitish,  and  apt  to  shrivel  and  become  dry  before  its 
separation.  In  the  latter  case,  as  best  exemplified  in  strangulated 
hernia,  the  bloodvessels  become  gradually  more  and  more  full,  and  the 
blood  more  dark,  till  the  walls  of  the  intestine,  passing  through  the 
deepest  tints  of  blood-color  and  of  crimson,  become  completely  black. 
Commonly,  by  partial  extravasation  of  blood,  and  by  inflammatory 
exudation,  they  become  also  thick,  firm,  and  leathery,  a  condition 
which  materially  adds  to  the  difficulty  of  reducing  the  hernia,  but 
which  is  generally  an  evidence  that  the  tissues  are  not  dead ;  for  when 
they  are  dead,  they  become  not  only  duller  to  the  eye,  but  softer, 
more  flaccid  and  yielding,  and  easily  torn,  like  the  rotten  tissues  of 
other  mortified  parts.  The  canal,  which  was  before  cylindrical,  may 
now  collapse ;  and  now,  commonly,  the  odor  of  the  iutestinal  contents 
penetrates  its  walls. 

I  have  spoken  of  the  death  of  the  blood  as  coinciding  with  that  of  the 
part  in  whose  vessels  it  is  inclosed.  Very  commonly,  when  this  happens, 
coagulation  of  blood  ensues  in  the  vessels  for  some  distance  above,  i.  e., 

*  Among  the  products  of  decomposition  on  the  smfaces  of  wounds,  are  little  filaments 
and  flocculi  of  soft  orange,  or  brownish  yellow  substance,  often  seen,  but  particularly  de- 
scribed first  by  Zeis  (Memoires  de  la  Soc.  de  Biologie.  Annee  1855).  They  are  shreds  of 
connective  tissue  (generally)  mingled  with  fatty  and  molecular  matter,  which  may  be  co- 
lored, and  with  crystals  of  cholesterine. 


SEPARATION    OF    MOETIFIED    PARTS.  319 

nearer  to  the  heart  than  the  mortified  parts.  Hence,  as  it  has  been 
often  observed,  no  bleeding  may  occur  from  even  large  arteries  divided 
in  amputations  above  the  dead  parts  of  sloughing  limbs. 

It  remains  now  to  speak  of  the  phenomena  which  ensue  when  gan- 
grene ceases,  and  of  which  the  end  is,  that  the  dead  parts  are  separated 
from  the  living. 

As  for  the  dead  parts,  they  only  continue  to  decompose,  while,  if 
exposed  to  a  dry  atmosphere,  they  gradually  shrivel,  becoming  drier 
and  darker.  But  more  important  changes  ensue  in  the  living  parts 
that  border  them.  The  first  change  that  occurs  in  this  process  (the 
whole  of  which  may  be  studied  as  the  most  remarkable  instance  of  the 
adaptation  of  disease  for  the  recovery  of  health),  the  first  indication  of 
the  coming  reparative  process,  is  a  more  decided  limitation  and  contrast 
of  color  at  the  border  of  the  dying  part.  As  we  watch  it  in  the  in- 
teguments, the  dusky  redness  of  the  surrounding  skin  becomes  more 
bright,  and  paler,  as  if  mingled  with  pink  rather  than  with  brown;  and 
the  contrast  reaches  its  height  when,  as  the  redness  of  the  living  part 
brightens,  the  dead  whiteness  or  blackness  of  the  slough  becomes  more 
perfect.  The  touch  may  detect  a  corresponding  contrast :  the  living 
part,  turgid  with  moving  blood,  feels  tense  and  warm ;  the  dead  part  is 
soft,  or  inelastic,  cold,  and  often  a  little  sunken  below  the  level  of  the 
living.  These  contrasts  mark  out  the  limits  of  the  two  parts :  they 
constitute  the  "■  line  of  demarcation"  between  them. 

The  separation  of  the  dead  and  living  parts,  which  remain  continuous 
for  various  periods  after  the  mortification  has  ceased,  and  the  line  of 
demarcation  is  formed,  is  accomplished  by  the  ulceration  of  the  portions 
of  the  living  tissues  which  are  immediately  contiguous  to  the  dead.  At 
this  border,  and  (in  parts  that  are  exposed)  commencing  at  the  surface, 
a  groove  is  formed  by  ulceration,  which  circumscribes  and  intrenches 
the  dead  part,  and  then,  gradually  deepening  and  converging,  under- 
mines it,  till,  reaching  its  centre,  the  separation  is  completed,  and  the 
slough  falls  or  is  dislodged  by  the  discharge  from  the  surface  of  the 
ulcerated  living  part.  Commonly,  before  the  border  of  the  integuments 
ulcerates,  it  becomes  white  and  very  soft,  so  that,  for  a  time,  a  dull 
white  line  appears  to  divide  the  dead  and  living  parts. 

Closely  following  in  the  wake  of  this  process  of  ulceration  is  one 
more  definitely  directed  towards  repair.  As  the  ulcerated  groove 
deepens  day  by  day  around  and  beneath  the  dead  part,  so  do  granula- 
tion-cells rise  from  its  surface ;  so  that,  as  one  might  say,  that  which 
was  yesterday  ulcerating,  is  to-day  granulating;  and  thus  very  soon 
after  the  slough  is  separated,  the  whole  surface  of  the  living  part,  from 
which  it  was  detached,  is  covered  with  granulations,  and  proceeds,  like 
an  ordinary  ulcer,  towards  healing. 

There  is,  I  believe,  nothing  in  the  method  of  thus  separating  a  dead 
part,  thus  "  casting  off  a  slough,"  which  is  not  in  conformity  with  the 


320  SEPARATION    OF    MORTIFIED    PARTS. 

general  process  of  ulceration.  When  a  portion  of  the  very  interior 
substance  of  an  organ  dies,  and  is  separated,  there  may  be  doubt,  as  in 
some  nearly  corresponding  cases  of  ulceration,  whether  the  clearing 
away  of  the  living  tissue  adjacent  to  it  be  effected  by  absorption  or  by 
disintegration,  and  mingling  with  the  fluid  in  which,  after  separation, 
the  dead  piece  lies.  "We  may  have  this  doubt  in  such  cases  as  the 
sloughing  of  subcutaneous  tissue  in  carbuncles  not  yet  open,  or  in  phleg- 
monous erysipelas,  or  in  cases  of  internal  necrosis ;  in  which,  without 
any  external  discharge,  pieces  of  dead  tissue  are  completely  detached 
from  the  living  tissue  around  them  :  and  I  do  not  know  how  such  doubt 
can  be  solved.  But  the  separation  of  superficial  or  exposed  dead  parts 
might  be  studied  as  the  type  of  the  ulcerative  process,  of  which,  indeed, 
it  is  in  disease  the  usual  beginning,  and  with  the  more  advantage,  be- 
cause the  sloughing  of  parts  of  limbs  affords  illustrations  of  the  process 
in  tissues  in  which  it  very  rarely  happens  otherwise.  Especially,  it 
shows  the  times  at  which,  in  different  tissues,  ulceration  may  ensue, 
and  hereby  the  times  during  which,  under  similar  conditions  of  hindered 
nutrition,  the  tissues  may  severally  maintain  life. 

The  process  which  I  have  exemplified  by  the  mortification  of  soft 
parts  has  an  exact  and  instructive  parallel  in  necrosis  or  mortification 
of  bone  ;  but  there  are  in  the  phenomena  of  necrosis  some  things  which 
deserve  a  brief  mention,  because  of  their  clearly  illustrating  the  general 
nature  of  the  process  following  the  death  of  a  part. 

Thus  (1)  we  find  in  bones  a  permanent  evidence  of  the  increase  of 
vascularity  of  the  tissues  around  a  dead  part;  for,  in  specimens  of  ne- 
crosis, the  bone  at  the  border  of  the  dead  piece  has  always  very  nu- 
merous and  enlarged  Haversian  canals.*  (2)  We  may  often  see  that 
the  reparative  process,  on  the  borders  of  the  living  part,  keeps  pace 
with,  or  rather  precedes  by  some  short  interval,  the  process  by  which 
the  living  and  the  dead  are  separated :  for  new  bone  is  always  formed 
in  and  beneath  the  periosteum  at  the  border  of  the  living  bone,  while 
the  groove  around  the  dead  piece  is  being  deepened,  or  even  before  its 
formation  has  commenced.  (3)  Instances  of  necrosis  show  some  of  the 
progressive  changes  that  lead  to  the  formation  of  the  groove  of  separa- 
tion. The  bone  at  the  very  junction  of  the  living  and  the  dead  becomes, 
first,  soft  and  ruddy,  as  an  inflamed  bone  does.  Its  earthy  matter,  as 
Mr.  Hunter  described,  is  first  (by  absorption,  as  we  must  suppose)  re- 
moved in  larger  proportion  than  its  animal  basis.  This  basis  remains, 
for  a  time,  connecting  the  dead  and  the  living  bone,  both  of  which 
retaining  their  natural  hardness,  appear  in  strong  contrast  with  it ;  but 
soon  this  also  is  removed,  and  the  separation  is  completed.     (4)  From 

*  In  these  enlarged  canals,  as  well  as  in  the  lacunae,  which  also  undergo  increase  in 
size,  an  abundant  growth  of  cells,  which  fill  their  cavities,  takes  place.  By  the  formation 
of  pus  from  these  cells,  the  dead  bone  is  separated,  or,  as  it  were,  floated  off.  J.  Goodsir, 
op.  cit.  :  Virchow,  Cell.  Pathologie. 


SPECIFIC    DISEASES.  321 

some  cases  of  necrosis,  also,  we  obtain  evidence  on  a  question  about 
the  removal  of  dead  tissue.  It  is  asked  whether  dead  tissue  may  not 
be  absorbed,  and  so  removed.  Examples  of  necrosis  show  that,  in  the 
large  majority  of  cases,  the  separation  of  dead  bone  is  accomplished 
entirely  by  the  ulceration  or  absorption  of  the  living  bone  around  it ; 
but  that,  in  certain  cases,  especially  in  those  in  which  pieces  of  bone, 
though  dead,  remain  continuous  with  the  living,  the  dead  bone  may  be 
in  part  absorbed,  or  otherwise  removed,  not  indeed  in  mass,  but  after 
being  disintegrated  or  dissolved.*  (5)  In  cases  of  necrosis  we  find  the 
best  examples  in  which,  apparently  through  want  of  vital  force,  the 
dead  and  living  parts  remain  long  united  and  continuous.  A  piece  of 
dead  bone,  proved  to  be  dead  by  its  blackness,  insensibility,  and  total 
absence  of  change,  may  remain  even  for  months  connected  with  living 
bone:  and  no  process  for  its  separation  is  established,  till  the  patient's 
general  health  improves.  (6)  Lastly,  in  the  death  of  bone,  we  may  see 
a  simpler  process  for  the  separation  of  the  living  tissues  than  that  which 
is  accomplished  by  ulceration.  In  superficial  necrosis,  the  periosteum, 
at  least  in  those  parts  in  which  its  own  tissue  does  not  penetrate,  so  as 
to  be  continuous  with,  that  of  the  bone,  separates  cleanly  from  the  sur- 
face of  the  dead  bone,  retaining  its  own  integrity  and  smoothness,  and 
leaving  the  bone  equally  entire  and  smooth.  IS^o  observations  have  yet 
been  made,  I  believe,  which  show  how  this  retirement  of  one  tissue 
from  another  is  effected,  or  how  the  bloodvessels  that  pass  from  one  to 
the  other  are  disposed  of.  Another  method  of  separation  without  the 
ulcerative  process  is  observed  when  teeth  die,  especially  in  old  persons. 
Their  sockets  enlarge,  apparently  by  mere  atrophy  or  absorption  of 
their  walls  and  margins  ;  so  that  the  teeth-fangs  are  no  longer  tightly 
grasped  by  them,  but  become  loose,  and  project  further  from  the  jaw. 


LECTURE   XX. 

SPECIFIC    DISEASES. 

It  would  be  far  beyond  the  design  of  these  lectures,  intended  only 
for  the  illustration  of  the  General  Principles  of  Pathology,  in  its  rela- 
tions with  Surgery,  if  I  were  to  enter  largely  on  the  consideration  of 

*  Such  cases  are  recorded  by  Mr.  Stanley,  in  whose  Treatise  on  Diseases  of  the  Bones  I 
need  hardly  say  that  all  the  phenomena  of  necrosis  are  much  more  fully  described  than  they 
are  here.  The  possibility  of  the  absorption  of  dead  bone  seems  amply  proved  by  cases 
(one  of  which  I  watched  while  it  was  under  his  care)  in  which  portions  of  pegs  of  ivory, 
driven  like  nails  into  bones,  to  excite  inflammation  for  the  repair  of  ununited  fractures,  have 
been  removed.  The  absorption,  I  say,  seems  amply  proved;  but  the  method  of  it  is  made, 
by  the  same  observations,  more  difficult  than  ever  to  explain;  for  only  those  portions  of  the 
ivory  that  were  imbedded  in  the  bone  were  absorbed ;  the  portions  that  were  not  in  contact 
with  bone,  though  imbedded  in  granulations  or  pus,  were  unchanged. 


322  DISTINCTIONS    BETWEEN    COMMON 

the  diseases  named  specific.  It  will  be  sufiicient,  I  hope,  and  certainly 
will  more  nearly  correspond  with  the  rest  of  my  plan,  if  I  describe  the 
general  features  of  specific  diseases,  and  their  general  import ;  and  if  I 
point  out,  though  only  in  suggestions,  how  we  may  more  efiectually 
study  them ;  how  many  things  relating  to  them,  which  we  are  apt  to 
dismiss  with  words,  may  be  subjects  of  deeper,  and  perhaps  useful, 
thought. 

The  term  "specific  disease,"  as  employed  m  common  usage  and  in 
its  most  general  sense,  means  something  distinct  from  common  or  simple 
disease.  Thus,  when  a  "  specific  inflammation,"  or  a  "  specific  ulcer," 
is  spoken  of,  we  understand  that  these  present  certain  features  in  which 
they  difi'er  from  what  the  same  person  would  call  "  a  common,"  or  a 
"simple  inflammation,"  or  "ulcer."  The  specific  characters  of  any 
disease,  whether  syphilis  or  hydrophobia,  gout  or  rheumatism,  typhus, 
small-pox,  or  any  other,  are  those  in  which  it  constantly  deviates  from 
the  characters  of  a  common  or  simple  disease  of  the  same  general  kind.* 
Our  first  inquiry,  therefore,  must  be, — what  are  these  common  diseases, 
which  we  seem  to  be  agreed  to  take  as  the  standard  by  Avhich  to  measure 
the  specific  characters  of  others  ? 

I  believe  that,  in  relation  to  inflammatory  diseases  and  their  con- 
sequences, our  chief  thoughts  concerning  such  standards  for  compari- 
son are  derived  from  the  affections  which  follow  injuries  by  violence,  or 
by  inorganic  chemical  agents,  by  heat,  or  any  other  commonly  applied 
causes  of  disease.  When  such  a  blow  is  inflicted  as  kills  a  portion  of 
'  the  body,  its  consequences  afford  a  standard  with  which  we  may  com- 
pare all  other  instances  of  mortification  and  sloughing ;  and  when, 
among  these,  we  find  a  certain  number  of  examples  which  difi'er,  in 
some  constant  characters,  from  this  standard,  we  place  them,  as  it 
were,  in  a  separate  group,  as  examples  of  a  specific  disease.  Or,  again, 
when  a  part  is  submitted  to  such  pressure  as  leads  to  its  ulceration,  we 
regard  the  disease  as  a  common,  simple,  or  standard  ulcer  ;  and  by 
their  several  constant  difi'erences  from  it,  and  from  one  another,  we 
judge  of  the  various  ulcers  which  we  name  specific.  In  like  manner, 
our  standard  of  common  or  simple  inflammation  seems  to  be  derived 
from  the  processes  which  follow  violence ;  the  application  of  heat,  the 
lodgement  of  foreign  bodies,  or  the  application  of  certain  chemical 
stimulants.  And  the  standard  of  common  or  simple  fever  is  that  which 
ensues  in  a  previously  healthy  man,  soon  after  he  has  received  some 
such  local  injury  as  any  of  these  agents  might  produce.     Now,  it  is 

*  It  may  not  be  unnecessary  to  guard  some  students  at  once  from  the  suspicion,  which 
the  terms  in  common  use  may  suggest,  that  there  is  a  correspondence  between  the  species 
of  diseases  and  those  of  living  creatures  as  studied  in  natural  history.  There  is  really  no 
likeness,  correspondence,  or  true  analogy  between  them  ;  and  if  nosological  systems,  framed 
after  the  pattern  of  those  of  zoology,  lead  to  the  belief  that  they  have  any  other  resemblance 
than  that  of  the  modes  of  briefly  describing,  and  of  grouping  double  names,  they  had  better 
be  disused. 


AND    SPECIFIC     DISEASES.  323 

very  reasonable  that  we  should  take  these  as  the  best  examples  of  com- 
mon or  simple  disease ;  the  best,  I  mean,  for  comparison  with  those 
that  may  be  called  specific.  For  not  only  can  we  produce  some  of 
these  common  diseases  when  we  will,  and  study  them  experimentally, 
but  they  manifestly  present  disease  in  its  least  complicated  form ;  least 
specified  by  peculiarities  either  in  its  cause  or  in  its  subject.  Only,  in 
adjusting  our  standards  of  disease  from  them,  it  is  necessary  that  we 
should  take  the  character  presented  by  all  or  by  the  great  majority  of 
instances ;  since  the  consequences  of  even  the  simplest  mechanical  in- 
juries are  apt  to  vary  according  to  the  peculiar  constitution  of  the 
person  injured. 

The  terms  simple  and  specific  are  sometimes  applied,  in  equal  con- 
tradistinction, to  tumors.  Here  we  have  no  such  standard  of  accidental 
or  experimental  'disease ;  but  that  which  seems  to  be  taken  as  the 
measure  of  simplicity  in  a  tumor,  is  the  conformity  of  its  structure  with 
some  of  the  natural  parts  of  the  body.  The  more  a  tumor  is  like  a 
mere  overgrowth  of  some  natural  structure,  the  more  "simple"  is  it 
considered ;  and  the  specific  characters  of  a  tumor  are  chiefly  those  in 
which,  whether  in  texture  or  in  mode  of  life,  it  differs  from  the  natural 
parts.  When,  however,  a  tumor  is  diseased, — for  instance,  when  a 
cancer  ulcerates, — the  specific  characters  of  the  ulcer  are  estimated  by 
comparison  with  the  characters  of  common  or  simple  ulcers. 

Such  are,  in  the  most  general  terms,  the  standards  of  common  or 
simple  diseases.  The  title  "  common"  applied  to  them  is,  in  another 
sense,  justified  by  the  features  which  they  present  being,  for  the  most 
part,  common  to  them  and  to  the  specific  diseases.  For,  in  the  specific 
diseases,  we  do  not  find  morbid  processes  altogether  different  from  those 
which  are  taken  as  standards,  but  only  such  processes  as  are  conformed 
with  them  in  all  general  and  common  features,  but  differ  from  them  by 
some  modification  or  addition.  In  other  words,  no  specific  disease  is 
entirely  peculiar  or  specific ;  each  consists  of  a  common  morbid  process, 
whether  an  inflammation,  an  ulceration,  a  gangrene,  or  any  other,  and 
of  a  specific  modification  or  plan  in  some  part  thereof. 

Let  us  now  see  what  these  modifications,  these  specific  characters, 
are ;  and  here,  the  history  of  tumors  being  for  the  present  postponed, 
let  me  almost  limit  the  inquiry  to  a  comparison  of  the  inflammatory 
affections  of  the  two  kinds,  and  select  examples  from  only  such  as  are, 
by  the  most  general  consent,  called  specific ;  as  syphilis,  gout,  rheuma- 
tism, the  eruptive  fevers,  and  the  like. 

1.  Each  specific  disease  constantly  observes  a  certain  plan  or  con- 
struction in  its  morbid  process;  each,  as  I  just  said,  presents  the  phe- 
nomena of  a  common  or  simple  disease,  but  either  there  is  some  addition 
to  these,  or,  else,  one  or  more  of  these  are  so  modified  as  to  constitute 
a  specific  character ;  a  peculiarity  by  which  each  is  distinguished  at  once 
from  all  common,  and  from  all  other  specific  diseases.     Thus,  we  see  a 


324  DISTINCTIONS     BETWEEN    COMMON 

patient  with,  say,  two  or  three  annular  or  crescentic  ulcers  on  his  legs ; 
and,  if  we  can  watch  these,  they  are,  perhaps,  healing  at  their  concave 
borders  at  the  same  time  as  they  are  extending  at  their  convex  borders. 
Now,  here  are  all  the  conditions  that  belong  to  common  ulcers ;  and,  in 
different  instances,  we  might  find  these  ulcers  liable  to  the  variations  of 
common  ones,  as  being  more  or  less  inflamed  or  congested,  acute  or 
chronic,  progressive  or  stationary ;  but  we  look  beyond  these  characters, 
and  see,  in  the  shape  and  mode  of  extension  of  these  ulcers,  properties 
which  are  not  observed  in  common  ones ;  we  recognize  these  as  specific 
characters ;  we  may  call  the  ulcers  specific ;  or,  because  we  know  how 
commonly  such  ulcers  occur  in  syphilis,  and  how  rarely  in  any  other 
disease,  we  call  them  syphilitic  ulcers,  and  treat  them  with  iodide  of 
potassium,  or  some  other  specific ;  that  is,  specially  curative  medicines. 
Another  patient  has,  say,  numerous  small,  round,  dusky,  or  light  brown- 
ish-red, slightly  elevated  patches  of  inflammation  of  the  surface  of  his 
skin ;  on  many  of  them  there  are  small,  dry,  white  scales ;  and  some  of 
them  may  be  arranged  in  a  ring'.  Here,  again,  are  the  common  charac- 
ters of  inflammation:  but  they  are  peculiarized  in  plan  and  tint  of  red- 
ness, and  in  general  aspect ;  and  because  of  these  we  regard  the  disease 
as  specific,  and  call  it  psoriasis,  and,  because  of  the  additional  peculiarity 
of  dusky  or  coppery  redness,  and  of  the  annular  or  some  other  figurative 
arrangement,  we  suspect  that  it  is  syphilitic  psoriasis.  Or,  we  look 
through  a  series  of  preparations  of  ulcerated  intestines ;  and  we  call  one 
ulcer  simple  or  catarrhal,  another  typhous,  another  dysenteric,  a  fourth 
tuberculous  :  all  have  the  common  characters  of  ulcers;  but  these  are, 
in  each,  peculiarly  or  specifically  modified  in  some  respect  of  plan;  and 
the  modifications  are  so  constant,  that  without  hearing  any  history  of 
the  specimens,  we  may  be  sure  of  all  the  chief  events  of  the  disease  by 
which  each  ulcer  was  preceded.  Or,  among  a  heap  of  diseased  bones, 
we  can  select  those  whose  possessors  were  strumous,  rheumatic,  syphi- 
litic, or  cancerous ;  finding  in  them  specific  modifications  of  the  results 
of  some  common  diseases,  such  as  new  bone,  i.  e.  ossified  inflammatory 
deposits,  arranged  in  peculiar  methods  of  construction,  or  at  particular 
parts ;  or  ulcers  of  peculiar  shape  and  peculiar  method  of  extension. 

I  need  not  cite  more  examples  of  the  thousand  varieties  in  which  the 
common  phenomena  of  disease  are  modified  in  specific  diseases.  In 
some,  the  most  evident  specific  characteristics  are  peculiar  affections  of 
the  movement  of  the  blood,  as  in  the  cutaneous  erythemata ;  in  some, 
affections  of  certain  parts  of  the  nervous  centres,  as  in  tetanus,  hydro- 
phobia, and  hooping-cough ;  in  some,  peculiar  exudations  from  the  blood, 
as  in  gout,  and  the  inoculable  diseases ;  in  some,  peculiar  structures 
formed  by  the  exuded  materials,  as  in  variola,  vaccinia,  and  other  cuta- 
neous pustular  eruptions ;  in  some,  destruction  of  tissues,  as  in  the  ulcers 
of  syphilis,  the  sloughs  of  boils  and  carbuncles ;  in  some,  peculiar 
growths,  as  in  cancer ;  in  some,  or  indeed  in  nearly  all,  peculiar  me- 
thods of  febrile  general  disturbance ;  but,  in  each  of  all  the  number, 


AND     SPECIFIC     DISEASES.  ^  325 

the  phenomena  admit  of  distinction  into  those  of  common  disease,  and 
those  in  which  such  disease  is  peculiarly  modified,  or  by  which,  if  I  may 
so  say,  it  is  specificated. 

The  morbid  process  thus  modified  may  be  local  or  general.  Usually, 
in  specific  diseases,  both  local  and  general  morbid  processes  are  concur- 
rent, and  both  are,  in  a  measure,  specific ;  but,  although  we  can  scarcely 
doubt  that  there  is  in  every  case  an  exact  and  specific  correspondence 
between  the  two,  yet,  at  present,  the  general  or  constitutional  afiections 
of  many  diiferent  specific  diseases  appear  so  alike,  that  we  derive  our 
evidence  of  specific  characters  almost  entirely  from  the  local  part  of 
the  disease.  The  premonitory  general  disturbances  of  the  exanthe- 
mata, or  the  slighter  disorders  preceding  cutaneous  eruptions,  are,  seve- 
rally, so  alike,  that,  except  by  collateral  evidence,  we  could  seldom  do 
more  than  guess  what  they  portend ;  their  specific  modifications  of  com- 
mon general  disturbance  are  too  slight  for  us  to  recognize  them  with  our 
present  knowledge  and  means  of  observation. 

2.  Observing  the  causes  of  specific  diseases,  we  find  that  some,  and 
these  the  most  striking  examples  of  the  whole  class,  are  due  to  the 
introduction  of  peculiar  organic  compounds, — morbid  poisons,  as  they 
are  generally  called, — into  the  blood.  Such  are  all  the  diseases  that 
can  be  transmitted  by  inoculation,  contagion,  or  infection.  All  these 
are  essentially  specific  diseases  ;  each  of  them  is  produced  by  a  distinct 
substance,  and  each  produces  the  same  substance,  and  by  a  morbid  pro- 
cess separates  it  from  the  blood.  In  most  of  these,  also,  as  well  as  in 
many  of  which  the  causes  are  internal  and  less  evident,  the  local  phe- 
nomena are  preceded  by  some  affection  of  the  whole  economy  ;  the 
whole  blood  seems  diseased,  and  nearly  every  function  and  sensation  is 
more  or  less  disturbed  from  its  health;  the  patient  feels  "ill  all  over," 
before  the  local  disease  appears ;  i.  e.  before  the  more  distinct  and 
specific  morbid  process  is  manifest  in  the  place  of  inoculation,  or  in 
some  other  part.  Herein  is  a  very  general  ground  of  distinction  be- 
tween the  specific  and  the  simple  or  common  diseases  :  in  the  latter,  the 
local  phenomena  precede  the  general  or  constitutional ;  in  the  former, 
the  order  is  reversed.  We  might,  indeed,  expect  this  to  be  a  constant 
difference  between  the  two  ;  and  perhaps  it  is  so ;  for  though  many 
exceptions  to  any  rule  founded  on  it  might  be  adduced,  yet  these  may 
be  ascribed  to  the  unavoidable  sources  of  fallacy  in  our  observations. 
Thus,  every  severe  injury,  every  long-continued  irritation,  excites  at 
once  both  local  and  general  disease ;  and  the  latter  may  be  evident 
before  the  former,  and  may  not  only  modify  it,  but  may  seem  to  pro- 
duce it.  On  the  other  hand,  the  insertion  of  certain  specific  poisons, 
e.  g.  that  of  the  venom  of  a  serpent  or  an  insect,  gives  rise  so  rapidly 
to  specific  local  disease,  that  this  seems  to  precede  all  constitutional 
affection. 

Notwithstanding  such  exceptions  as  these  are,  or  seem  to  be,  this 
contrast  between  specific  and  common  diseases,  in  regard  to  the  order 


326  *■   DISTINCTIONS    BETWEEN    COMMON 

in  which  the  local  and  constitutional  symptoms  arise,  is  so  usual  that 
the  terms  specific  and  constitutional  a,re  often  employed  as  convertible 
terms  in  relation  to  disease.  But  this  is  not  convenient ;  for  some  spe- 
cific diseases  are,  or  become,  local ;  and  some  constitutional  diseases  are 
not  specific. 

3.  A  character  very  generally  observed  in  specific  diseases  is  an- 
apparent  want  of  proportion  between  the  cause  and  the  effect.  In 
common  disease,  one  might  say  that,  on  the  whole,  the  quantity  of  local 
disease  is  in  direct  proportion  to  the  cause  exciting  it — whether  violent 
injury,  heat,  poison,  or  any  other.  Numerous  exceptions  might  be 
found,  but  this  is,  on  the  whole,  the  rule.*  In  specific  diseases  there 
is  no  appearance  of  such  a  rule  :  we  cannot  doubt  its  existence,  but  it  is 
lost  sight  of.  Thus,  in  small-pox,  measles,  hydrophobia,  or  syphilis, 
the  severity  of  the  disease  is  not,  evidently,  proportionate  to  the  cause 
applied ;  a  minimum  of  inoculated  virus  engenders  as  vast  a  disease  as 
any  larger  quantity  might. 

4.  I  have  said  that  there  is  generally  a  correspondence  between  the 
local  and  the  constitutional  characters  of  a  specific  disease ;  but  this  is 
only  in  respect  of  quality ;  in  respect  of  quantity  there  is  often  such  a 
want  of  correspondence  between  the  two  as  we  rarely  or  never  see  in 
common  diseases.  In  general,  the  amount  of  common  inflammatory 
fever  after  an  operation  bears  a  direct  proportion  to  the  injury,  and  the 
amount  of  hectic  fever  to  the  quantity  of  local  disease  (here,  again,  are 
numerous  exceptions,  but  this  is  the  rule) :  but  in  specific  diseases  it  is 
far  otherwise.  In  syphilis  and  cancer,  the  severest  defects  or  disturb- 
ances in  the  whole  economy  may  coexist  with  the  smallest  amounts  of 
specific  local  disease ;  and,  as  Dr.  Robert  Williamsf  has  well  said,  "  It 
may  be  laid  down  as  a  general  law,  that  when  a  morbid  poison  acts  with 
its  greatest  intensity,  and  produces  its  severest  forms  of  disease,  fewer 
traces  of  organic  alteration  of  structure  will  be  found  than  when  the 
disorder  has  been  of  a  milder  character." 

5.  To  specific  diseases  belong  all  that  was  said,  in  former  Lectures 
(p.  35  e.  s.),  of  the  symmetrical  diseases,  and  of  seats  of  election  :  such 
phenomena  occur  in  degenerations,  but,  I  think,  in  no  common  diseases. 

6.  The  local  process  of  a  specific  disease  of  nutrition  is  less  apt  than 
that  of  a  common  one  to  be  nearly  limited  to  the  area  in  which,  in  the 
first  instance,  the  cause  of  disease  was  applied.  Specific  diseases  are 
peculiarly  prone  to  spread,  that  is,  to  extend  their  area.  They  also, 
among  the  diseases  of  nutrition,  are  alone  capable  of  being  erratic,  i.  e. 
of  disappearing  from  the  part  in  which  they  were  first  manifest,  while 

*  I  am  tempted  to  say  here,  that,  in  pathology,  we  must  admit  the  existence  of  many 
rules  or  laws  the  seeming  exceptions  to  which  are  more  numerous  than  the  plain  examples 
of  them.  This,  however,  is  not  enough  to  invalidate  the  truth  of  the  laws:  it  could  scarcely 
be  otherwise  in  the  case  of  laws,  the  exact  observance  of  which  requires  the  concurrence  of 
so  many  conditions  as  are  engaged  in  nearly  all  the  phenomena  studied  in  pathology. 

f  Elements  of  Medicine,  vol.  i,  p.   12. 


AND    SPECIFIC    DISEASES.  327 

extending  thence  through  other  parts  continuous  -with  it ;  and  they 
alone  are  capable  of  metastasis,  i.  e.,  of  suddenly  ceasing  in  one  locality, 
and  manifesting  themselves,  with  similar  local  phenomena,  in  another. 

T.  In  all  the  particulars  mentioned  in  the  last  preceding,  and  in  some 
of  the  earlier  paragraphs,  specific  diseases  manifest  a  peculiar  character, 
in  that  they  seem  capable  of  self-augmentation  ;  no  evident  fresh  cause 
is  applied,  and  yet  the  disease  increases  :  witness  the  seemingly  spon- 
taneous increase  of  manifest  local  disease  in  secondary  and  tertiary 
syphilis,  or  in  the  increasing  eruption  of  eczema  or  of  herpes,  or  the  ex- 
tension of  a  carbuncle,  or  the  multiplication  of  secondary  cancers. 

8.  Specific  diseases  alone  are  capable  of  transformation  or  metamor- 
phosis. As  we  watch  a  common  disease,  its  changes  seem  to  be  only 
those  of  degree ;  it  appears  increasing  or  declining,  but  is  always  the 
same,  and  a  continuous  disease.  But  in  many  specific  diseases  we  see 
changes  in  quality  or  kind,  as  well  as  in  quantity.  In  syphilis,  for  ex- 
ample, a  long  series  of  diseases  may  occur  as  the  successive  conse- 
quences of  one  primary  disease  diiferent  from  them  all.  They  are  all, 
in  one  sense,  the  same  disease,  as  having  a  single  origin  ;  but  it  is  a 
disease  susceptible  of  change  in  so  far  as  it  manifests  itself  at  different 
times,  not  only  in  different  parts,  but  in  different  forms  in  each,  and  in 
forms  which  are  not  wholly  determined  by  the  nature  of  the  tissue 
affected.  The  successive  phenomena  of  measles,  scarlet  fever,  and 
many  others,  may,  I  think,  be  similarly  expressed  as  metamorphoses  or 
transformations  of  disease. 

9.  A  similar  transformation  of  specific  diseases  may  take  place  in 
their  transference  from  one  person  to  another,  whether  by  inheritance,* 
or  by  infection,  or  contagion.  A  parent  with  one  form  of  secondary 
syphilis  may  have  a  child  with  another  form  ;  the  child  of  a  parent  with 
scirrhous  cancer  may  have  an  epithelial,  a  colloid,  or  a  medullary  can- 
cer ;  the  inoculation  of  several  persons  with  the  matter  from  one  pri- 
mary syphilitic  sore  may  produce  different  forms  of  the  primary  disease 
and  different  consecutive  phenomena;  the  same  contagion  of  small-pox, 
measles,  or  scarlet  fever,  may  produce  in  different  subjects  all  the  modi- 
fications of  which  those  diseases  are  severally  capable  ;  the  puerperal 
woman,  or  the  patient  who  has  sustained  a  severe  accidental  or  surgical 
injury,  may  modify,  or,  as  it  were,  color,  with  the  peculiarities  of  her 
own  condition,  whatever  epidemic  or  other  zymotic  diseases  she  may 
incur,  f 

10.  Lastly,  time  is  a  peculiarly  important  condition  in  many  of  the 
specific  diseases.  If  we  except  the  period  of  calm  or  incubation,  which 
usually  occurs  between  the  infliction  of  an  injury  and  the  beginning  of 

*  It  might  seem  as  if  none  but  specific  diseases  could  be  hereditary ;  but  many  tumors 
are  so  which  we  cannot  well  call  specific  :  such  as  the  cutaneous  cysts  or  wens,  and  fatty 
and  cartilaginous  tumors. 

f  See  Carpenter;  Br.  and  For.  Med.-Chir.  Review,  Jan.  1853,  quoting  from  Simpson,  in 
Monthly  Journ.  of  Med.  Sc.  vol.  xi  and  xiii. 


328  THEORY    OF    SPECIFIC    DISEASES. 

an  evident  reparative  process,  a  period  of  which  the  length  is,  in  general, 
proportionate  to  the  severity  of  the  injury,  there  are  few  of  the  events 
of  common  diseases  that  are  periodic  or  measurable  in  time ;  there  are 
none  that  are  regularly  intermittent  or  remittent ;  none  that  can  be 
compared,  for  regularity,  with  the  set  times  of  latency  of  the  morbid 
poisons  of  the  eruptive  fevers,  or  the  periods  in  which  they  run  their 
course,  or  change  their  plan  or  chief  place  of  action.  Neither  are 
there,  in  common  diseases,  any  periods  of  latency  so  long  as  those 
which  elapse  between  the  application  of  the  specific  cause,  and  the  ap- 
pearance of  its  specific  efi'ect,  in  the  eruptive  fevers,  tetanus,  or  hydro- 
phobia. 

Such,  briefly,  are  the  chief  general  characters  of  the  diseases  which 
are  commonly  named  specific,  or  described  as  having  something  specific 
in  their  action.  In  some  of  them,  chiefly  such  as  depend  on  distinct 
morbid  poisons,  whether  miasma  or  virus,  or  matter  of  contagion,  all 
these  characters  may  be  observed  ;  and  these  are  the  best  types  of  the 
class.  In  others,  part  only  of 'the  same  characters  concur.  I  do  not 
pretend  to  define  the  exact  boundary  of  what  should  be  called  specific, 
and  what  common,  in  diseases ;  but  it  seems  reasonable  that  any  disease, 
in  which  the  majority  of  the  characters  just  enumerated  are  found, 
should  be  studied  as  one  of  the  class,  and  that  its  phenomena  should 
be  interpreted,  if  possible,  by  the  rules,  or  by  the  theory  derived  from 
the  more  typical  members  of  the  same  class. 

The  theory  of  specific  diseases,  in  its  most  general  terms,  is,  that 
each  of  them  depends  on  a  definite  and  specific  morbid  condition  of  the 
blood  ;  that  the  local  process  in  which  each  is  manifested  is  due  to  the 
disorder  produced  by  the  morbid  blood  in  the  nutrition  of  one  or 
more  tissues  ;  and  that,  generally,  this  disorder  is  attended  with  the  ac- 
cumulation, and  leads  to  the  discharge,  or  transformation,  of  some  mor- 
bid constituents  of  the  blood  in  the  disordered  part.  It  is  held,  also, 
that,  in  some  specific  diseases,  the  morbid  condition  of  the  blood  con- 
sists in  undue  proportions  of  one  or  more  of  its  normal  constituents ; 
and  that,  in  others,  some  new  morbid  substance  is  added  to  or  formed  in 
the  blood.  In  either  case,  the  theory  is,  that  the  phenomena  of  each 
specific  disease  depend  chiefly,  and  in  the  first  instance,  on  certain  cor- 
responding specific  materials  in  the  blood:  and  that  if  characteristic 
morbid  structures  be  formed  in  the  local  process,  they  are  organs  in 
which  these  morbid  materials  are  incorporated. 

Now,  in  regard  to  certain  diseases,  such  as  some  of  those  that  can  be 
communicated  by  inoculation,  these  terms  are  scarcely  theoretical;  they 
may  rather  be  taken  as  the  simplest  expressions  of  facts.  For  exam- 
ple (as  I  have  already  said,  p.  301)  in  either  syphilis,  vaccinia,  glanders, 
or  small-pox,  especially  when  produced  by  inoculation,  we  have  demon- 
stration (1)  of  a  morbid  condition  of  the  blood ;  (2)  of  the  definite  and 
specific  nature  of  that  condition,  in  that  it  is,  and  may  be  at  will,  pro- 


THEORY    OF    SPECIFIC    DISEASES.  329 

duced  by  the  introduction  of  a  definite  substance  into  the  blood,  and 
manifests  itself  in  a  local  disease  which,  within  certain  limits,  has  con- 
stant characters ;  and  (3)  of  the  same  substance  being  accumulated  and 
discharged,  or  for  a  time  incorporated  in  the  morbid  structures,  at  the 
seat  of  the  local  disease.  And  it  seems  important  to  mark,  that  all 
which  is  thus  seen  in  some  specific  diseases,  and  is  assumed  for  the  ex- 
planation of  others,  is  consistent  with  facts  of  physiology ;  especially 
with  those  referred  to  in  a  former  Lecture  (p.  40,  e.  s.),  as  evidences, 
that  certain  normal  organs  of  the  body  are  formed  in  consequence  of 
the  presence  of  materials  in  the  blood,  which,  in  relation  to  them,  might 
be  called  specific,  and  which  they,  in  their  formation,  take  from  the 
blood,  and  incorporate  in  their  own  structures.* 

The  proof  of  the  theory  of  specific  diseases  is  scarcely  less  complete 
for  all  those  that  are  infectious  or  contagious,  but  cannot  be  communi- 
cated by  inoculations — such  as  typhus,  measles,  erysipelas  ;  and  scarcely 
less  for  those  which  are  neither  infectious  nor  contagious,  but  depend, 
like  cholera  and  ague,  on  certain  materials  which  are  introduced  into 
the  blood,  and  produce  uniform  results,  though  they  are  not  proved  to 
exist  in  the  products  of  the  morbid  processes.  For  other  diseases, 
classed  or  usually  regarded  as  specific,  such  as  gout,  rheumatism,  car- 
buncle, boil,  the  various  definite,  but  not  communicable,  cutaneous 
eruptions,  hydrophobia,  tetanus,  and  many  more,  the  evidences  of  the 
theory  are  less  complete.  Yet  they  seem  not  insufiicient ;  while  we 
have,  in  many  of  these  afi"ections,  proofs  of  the  accumulation  and  sepa- 
ration of  morbid  substances  at  the  seats  of  local  disease,  and  while,  in 
all,  the  chief  phenomena  are  in  close  conformity  with  those  of  the  dis- 
eases which  are  typically  specific.  Relying  on  the  similarity  of  all  the 
members  of  the  group  of  specific  diseases,  on  the  sufliciency  of  the 
terms  of  the  theory  for  the  expression  of  the  facts  concerning  them 
all,  and  on  the  evidences  more  or  less  complete  which  each  of  them  sup- 
plies for  its  truth,  we  seem  justified  in  adopting  the  same  theory  for 
them  all.f 

■*  Abundant  illustrations  of  the  same  general  laws,  of  both  healthy  and  morbid  formation 
of  structures  incorporating  specific  materials  from  the  blood,  are  supplied  by  the  action  of 
medicines  whose  operation  ensues  in  only  certain  organs.  Dr.  Robert  Williams  (1.  c.  p.  8) 
has  justly  said,  "  The  general  laws  observable  in  the  actions  of  morbid  poisons  are,  for  the 
most  part,  precisely  similar  to  those  which  govern  medicinal  substances,  or  only  differ  in  a 
few  minor  points."  The  subject  is  too  extensive  for  discussion  here.  It  is  admirably 
treated  by  Mr.  Simon  in  his  Lectures  on  Pathology  ;  the  work,  which  together  with  that 
of  Dr.  Robert  Williams,  may  be  studied  with  more  profit  in  relation  to  all  the  subjects  of 
this  lecture  than  any  I  have  yet  read. 

f  Without  going  so  far  as  Virchow,  who  regards  every  enduring  change  in  the  circulating 
juices  as  derived  from  fixed  points  of  the  body,  from  single  organs  or  tissues,  and  who  looks 
for  "localization  for  the  different  dyscrasise ;"  that  is,  for  definite  tissues  from  out  of  which 
the  blood  derives  its  disturbance,  yet  it  may  be  reasonably  granted,  that  any  diseased  organ 
or  tissue  must,  through  the  nutritive  changes  which  take  place  between  it  and  the  blood, 
constantly  act  as  a  centre  or  focus,  from  which  a  disturbance  affecting  the  entire  mass  of 
blood  may  arise. 

22 


330  HISTORY    OF    MORBID    MATERIALS 

But  now,  if  we  may  hold  this  theory  to  be  true  for  some  specific  dis- 
eases, and  not  unreasonable  for  the  rest,  let  us  see  how,  in  its  terms,  we 
can  explain  or  express  the  chief  characters  of  these  diseases ;  such  as 
their  periodicity,  metastases,  and  metamorphoses,  the  apparent  increase 
of  the  specific  substance  in  the  blood,  and  the  others  just  enumerated. 
This  may  be  done  while  tracing  the  probable  history,  or,  as  I  would 
call  it,  the  life,  of  the  morbid  material  in  the  blood,  and  in  the  tissues.* 

Specific  morbid  materials,  or  at  least  their  chief  constituents,  may 
enter  the  body  from  without,  by  inoculation,  contagion,  or  infection : 
or  they  may  be  formed  in  the  blood,  or  added  to  it  within  the  body :  in 
other  words,  some  morbid  materials  are  inserted,  others  are  inbred,  in 
the  blood  ;  with  some,  probably,  both  modes  of  introduction  are  possible. 

Doubtless,  an  important  difi"erence  is  thus  marked  between  two  chief 
groups  of  the  specific  diseases  :  but  it  is  not  within  my  present  purpose 
to  dwell  on  it :  for  only  one  general  history  can  as  yet  be  written  for 
the  whole  class  of  morbid  materials  on  which  the  specific  diseases  de- 
pend :  and,  although  this  may  be  best  drawn  from  the  instances  of  those 
that  are  derived  from  without,  i.  e.,  from  such  as  are  called  morbid 
poisons,  yet  it  would  probably  be  as  true,  in  all  essential  features,  for 
those  that  are  inbred. 

When  a  morbid  poison  is  inoculated, — for  example,  when  the  matter 
from  a  syphilitic  sore,  or  from  a  vaccine  vesicle,  is  inserted  in  the 
skin — it  produces  a  specific  eifect  both  on  the  tissue  at  the  place  of  in- 
sertion, and  on  the  blood,  as  soon  as  it,  or  any  part  of  it,  is  absorbed : 
in  other  words,  it  produces  both  a  local  and  a  constitutional  change  ; 
and  in  both  these  efi"ects  its  history  must  be  traced. 

I.  First,  respecting  the  local  changes  of  which,  with  another  design, 
I  have  already  spoken  (p.  303).  It  is  not  proved  by  anything  that  can 
be  seen  immediately,  or  even  within  one  or  two  days  after  the  inocula- 
tion. The  place  of  inoculation  remains,  for  a  time,  apparently  unaf- 
fected :  and  yet  that  a  peculiar  change  is  being  wrought  in  it  is  clear, 
for  it  presently  becomes  the  seat  of  specific  disease,  the  materials  of 
which  disease  are  supplied  by  blood  that  nourishes  healthily  all  other 
parts,  even  such  parts  as  may  have  received  common  injuries  at  or  near 
the  time  of  the  inoculation.  The  inoculated  part,  therefore,  is  not 
merely  injured,  but  is  peculiarly  altered  in  its  relation  to  the  blood, 
which  now  nourishes  it  difierently  from  all  the  rest  of  the  body.  The 
change  of  the  blood  is  proved,  if  not  by  general  febrile  or  other  disturb- 
ance, yet  by  the  specific  character  of  the  presently  ensuing  disease,  and 
by  the  consecutive  secondary  disease,  or  by  consecutive  immunity  from 
later  disease  of  the  same  kind. 

■*  Several  of  the  characters  of  specific  diseases  are  already  explained,  in  the  terms  of  this 
theory,  in  the  earlier  Lectures:  namely,  their  specific  forms  and  constructions  (pp.  40,  44, 
63)  ;  symmetry  and  seats  of  election  (p.  35,  e.  s.)  ;  extension  and  errantry  (p.  37,  note). 


IN    THE    BLOOD    AND    TISS'UES.  331 

If  further  proof  be  needed  of  the  specific  local  change  produced  in 
the  inoculated  part,  it  may  be  furnished  by  the  analogy  of  the  more 
visible  effects  of  certain  animal  poisons, — such  as  those  of  venomous 
serpents  and  insects.  N'one  of  these  appear  to  be  simple  irritants  ;  the 
consequences  of  their  insertion  are  not  like  simple  inflammations,  but 
are  peculiar,  and  constant  in  their  peculiarities.  The  bite  of  a  bug  or 
a  flea  will  not,  I  hope,  be  thought  too  trivial  for  an  illustration. 

In  less  than  a  minute  after  the  bite,  the  bitten  part  begins  to  itch  ; 
and  quickly  after  this,  a  wheal  or  circumscribed  pale  swelling,  with  a 
nearly  level  surface,  and  a  defined  border,  gradually  rises  and  extends 
in  the  skin.  It  seems  to  be  produced  by  an  oedema  of  a  small  portion 
of  the  cutis  at  and  around  the  bite ;  it  is  not  a  simple  inflammatory 
swelling  ;  it  is,  from  the  first,  paler  than  the  surrounding  skin,  which 
may  be  healthy  or  slightly  reddened  by  afiiux  of  blood :  and  the  con- 
trast between  them  becomes  more  striking,  as  the  surrounding  skin 
becomes  gradually  redder,  as  if  with  a  more  augmented  fulness  of  the 
bloodvessels.  Thus,  for  some  minutes,  the  wheal  appears  raised  on  a 
more  general,  and  less  defined,  vascular  swelling  of  the  surrounding 
and  subjacent  tissues  ;  but,  after  these  minutes,  and  as  the  itching  sub- 
sides, the  wheal,  or  paler  swelling,  becomes  less  defined,  and  the  more 
general  swelling  appears  gradually  to  encroach  on  it  and  involve  it. 
Then  all  subsides :  but  only  for  a  time ;  for  in  about  twenty-four  hours 
a  papule,  or  some  form  of  secondary  inflammation,  appears,  with  re- 
newed itching,  at  the  seat  of  the  puncture,  and  this  after  one,  two,  or 
sometimes  more  days,  gradually  subsides.* 

Now,  the  first  pale  and  circumscribed  swelling  at  any  of  these  bites 
may  serve  to  illustrate  the  immediate  effects  of  a  morbid  poison  on  the 
tissues  at  and  around  the  seat  of  inoculation.  In  the  area  of  such  a 
swelling  the  tissues  are,  by  the  direct  contact  or  influence  of  the  venom, 
altered  in  their  nutritive  relation  to  the  blood.  So,  I  believe,  imme- 
diately after  the  insertion  of  syphilitic,  vaccine,  or  other  virus,  there 
ensues  a  corresponding  specific  alteration  of  those  parts  of  the  sur- 
rounding tissues  which  afterwards  become  seats  of  the  specific  local 
disease.f 

*  Some  persons  are  so  happily  constituted,  that  they  do  not  thus,  or  with  any  other  dis- 
comfort, suffer  the  consequences  of  insect-bites ;  but  I  think  the  description  I  have  given 
will  be  found  generally  true  for  cases  in  which  the  bitten  part  is  left  undisturbed ;  the  fortu- 
nate exempt  may  illustrate  the  rarer  exceptions  from  the  usual  influence  of  the  severer 
morbid  poisons. 

t  The  direct  influence  of  animal  poisons  on  the  tissues  appears  to  be  well  shown  in  the 
effects  of  the  bites  of  the  viper  and  rattlesnake.  Sir  B.  C.  Brodie  particularly  noticed  this 
in  a  man  bitten  by  a  rattlesnake  (Lectures  on  Pathology  and  Surgery,  p.  345).  The  pri- 
mary local,  though  widely  extended,  effect  of  the  poison  was  a  sloughing  of  the  cellular 
membrane,  which  began  ''  immediately  after  the  injury  was  received."  The  poison  "  seemed 
to  operate  on  the  cellular  membrane,  neither  in  the  direction  of  the  nerves,  nor  in  that  of 
the  absorbents,  nor  in  that  of  the  bloodvessels."  His  account  has  been  recently  confirmed 
in  a  more  quickly  fatal  case.  Many  years  ago,  one  of  my  brothers  was  stung  by  a  weever- 
fish  (Trachinus  Draco)  ;  and  I  remember  that  next  day,  though  no  severe  inflammation  had 


332  HISTORY    OF    MORBID     MATERIALS 

I  will  not  venture  to  say  that  the  secondary  inflammation,  which 
usually  appears  on  the  day  after  any  of  these  bites,  is  to  be  ascribed  in 
some  measure  to  an  influence  exercised  by  the  virus  on  the  blood ; 
though,  indeed,  this  will  not  seem  impossible  to  those  who  are  conside- 
rate of  the  effect  of  the  minutest  portion  of  vaccine  virus,  and  of  the 
intense  constitutional  disturbance  excited  by  the  other  venoms.  But, 
whatever  be  thought  on  this  point,  the  occurrence  of  a  new  and  different 
inflammation  in  the  bitten  part  proves  that  it  did  not  return  to  perfect 
health  when  its  flrst  affection  subsided ;  it  proves  that  some  altered 
material  of  the  virus,  or  some  changing  trace  of  its  effects  upon  the  tis- 
sues, remained,  altering  their  relation  to  the  blood,  and  making  them 
alone,  of  all  the  parts  of  the  body,  prone  to  specific  disease.  The  bitten 
part  thus,  in  its  interval  of  apparent  health,  instructively  illustrates  the 
state  of  parts  after  inoculation  with  syphilitic  or  vaccine  virus.  In 
them,  as  in  it,  we  must  suppose  that  some  virus,  or  some  specific  effect 
produced  by  it  on  the  tissues,  remains  during  all  that  period  of  latency, 
or  incubation,  as  it  is  called,  which  intervenes  between  the  inoculation 
and  the  appearance  of  the  specific  disease. 

Whatever  be  the  state  thus  indirectly  induced  in  the  inoculated,  or 
bitten  part,  let  it  be  noted  as  one  constantly  changing.  The  tissues  of 
the  part,  like  the  rest  of  the  body,  are  engaged  in  the  constant  muta- 
tions of  nutrition ;  and  the  morbid  material  in  the  part  is  probably, 
like  every  organic  matter,  in  constant  process  of  transformation.  Some 
of  the  local  phenomena  of  specific  diseases  indicate  these  progressive 
changes  in  the  part  itself;  but  they  can  scarcely  be  traced  separately 
from  those  that  are  occurring  in  the  morbid  material  absorbed  in  the 
blood. 

The  local  and  peculiar  change  produced  by  the  direct  effect  of  the 
morbid  poison  is  essential  to  the  complete  manifestation  of  some  specific 
diseases.  In  many  others,  as  in  typhus,  variola,  acute  rheumatism, 
and  gout,  the  morbid  condition  of  the  blood  is  sufficient  to  determine 
the  local  disease  in  tissues  previously  healthy.  But  it  is,  perhaps,  true 
for  all,  that  the  existence  of  some  part  whose  nutrition  is  depressed, 
whether  through  simple  or  specific  injury,  is  very  favorable  to  the 
manifestation  of  the  constitutional  disease  (see  p.  302).  Thus,  I  shall 
have  to  mention  cases  of  cancer  in  which  the  constitutional  condition, 
or  diathesis,  seems  to  have  been  latent  till  some  local  injury  brought  a 
certain  part  into  a  state  apt  for  the  cancerous  growth, — the  diathesis, 
as  one  may  say,  waited  for  the  necessary  local  condition.  In  like 
manner,  cases  sometimes  occur  in  which  constitutional  syphilis  is  justly 
presumed  to  exist,  but  in  which  it  has  no  local  manifestation  till  some 
part  is  appropriated  for  it  by  the  effects  of  injury.  I  know  a  gentle- 
man, who,  for  not  less  than  five  years  after  a  syphilitic  affection  of  the 
testicle,  had  no  sign  of  syphilis,  except  that  of  generally  feeble  health  ; 

intervened,  there  was  a  little  black  slough  at  the  puncture,  as  if  the  venom  had  completely 
killed  a  piece  of  the  skin. 


IN    THE    BLOOD    AND    TISSUES.  333 

but  he  accidentally  struck  his  nose  severely,  and  at  once  a  well-marked 
syphilitic  disease  of  its  bones  ensued.  In  another  case,  syphilitic  dis- 
ease of  the  skull  followed  an  injury  of  the  head.  In  similar  cases, 
ulcers  like  those  of  tertiary  syphilis  have  appeared  in  healing  operation- 
wounds,  I  lately  saw  a  gentleman  who  had  long  suffered  with  diabetes, 
a  condition  with  which,  as  is  well  known,  boils  often  coincide.  He, 
however,  had  none,  till  he  accidentally  struck  his  leg,  and  the  injury 
was  quickly  followed  by  a  succession  of  more  than  twenty  boils  near 
the  injured  part.  And,  in  like  manner,  as  I  have  stated  in  a  former 
Lecture  (p.  303),  even  variola  and  measles  may  have  their  intensest 
local  manifestations  in  injured  parts. 

I  need  not  dwell  on  the  importance  of  cases  such  as  these,  for  caution 
against  supposing  that  the  diseases  which  seem  to  originate  in  local 
injury  are  only  local  processes.  The  most  intense  constititutional 
affections  may  appear  almost  irrespective  of  locality,  able  to  manifest 
themselves  in  nearly  every  part ;  but  the  less  intense  may  abide  un- 
observed, so  long  as  all  the  tissues  are  being  maintained  without  ex- 
ternal hindrance  or  interference  ;  they  may  be  able  to  manifest  them- 
selves only  in  some  part  whose  normal  power  of  maintenance  is  disturbed 
by  injury  or  other  disease.  It  may,  generally,  also,  be  noticed  that 
the  more  intense  the  constitutional  affection,  and  the  less  the  need  for 
preparation  of  a  locality  for  its  manifestation,  the  less  tenacious  is  it 
of  its  primary  seat.  Contrast,  for  example,  in  this  respect,  the  fuga- 
city  of  acute  rheumatism  or  gout  with  the  tenacity  of  chronic  rheuma- 
tism in  some  locality  of  old  disease  or  injury.* 

II.  Respecting,  secondly,  the  changes  which  a  morbid  material, 
inoculated  and  absorbed,  may  undergo  in  the  blood,  these  may  be  enu- 
merated as  the  chief, — increase,  transformation,  combination,  and 
separation  or  excretion.  Here,  again,  one  assumes  for  an  example 
such  a  morbid  material  as  may  be  inoculated  ;  but  it  will  be  plain  that 
most  of  what  is  said,  in  the  following  illustrations,  might  also  be  said 
of  those  that  are  otherwise  introduced  into  the  blood  ;  and  further, 
that  the  particulars  of  the  life  of  these  morbid  materials  are  generally 
consistent  with  those  of  ordinary  constituents  of  the  blood, 

(a)  The  increase  of  the  morbid  material  in  the  blood  is  illustrated  in 
syphilis,  small-pox,  vaccinia,  glanders.  In  any  of  these,  the  inoculation 
of  the  minutest  portion  of  the  virus  is  followed  by  the  formation  of  one 
or  more  suppurating  structures,  from  which  virus,  similarly  and  equally 
potent,  is  produced  in  million-fold  quantity.  So,  the  matter  of  any 
contagion  working  in  one  person  may  render  his  exhalation  capable  of 
similarly  affecting  a  thousand  others. 

*  Dr.  Carpenter  (1.  c.)  has  clearly  traced  that  epidemic  and  other  zymotic  influences 
bear,  with  peculiar  force,  on  those  in  whose  blood  there  is  "  an  accumulation  of  disintegra- 
ting azotized  compounds  in  a  state  of  change."  Is  it  not  a  similar  degenerate  condition 
\vrhich  makes  an  injured  part  peculiarly  amenable  to  the  influence  of  specific  morbid  mate- 
rials in  the  blood  ? 


334  HISTORY    OF    MORBID    MATERIALS 

The  increase  is  thus  evident.  The  effect  of  the  inoculated  morbid 
poison  may  be  compared  with  that  of  a  ferment  introduced  into  some 
azotized  compound,  in  some  of  the  materials  of  which,  it  excites  such 
changes  as  issue  in  the  production  of  material  like  itself.  What  are 
the  materials  of  the  blood  thus  changed  and  converted  to  the  likeness 
of  the  morbid  poison  we  cannot  tell.  The  observations  of  Dr.  Carpen- 
ter,* showing  how  peculiarly  liable  to  all  contagious  and  other  zymotic 
influences  they  are  whose  blood  is  surcharged  with  decomposing  azotized 
materials,  may  well  lead  us  to  believe  that  it  is  among  these  materials 
that  many  of  the  morbid  poisons  find  the  means  of  their  increase.  And, 
as  Mr.  Simonf  argues,  it  seems  nearly  sure  that  certain  of  these 
poisons,  in-  their  increase,  so  convert  some  material  of  the  blood,  that 
they  wholly  exhaust  it,  and  leave  the  blood  for  a  long  time,  or  for  life, 
incapable  of  being  again  affected  by  the  same  morbid  poison. 

The  increase  of  the  morbid  material,  however  effected,  explains  these 
characters  of  specific  diseases :  the. apparent  disproportion  between  the 
specific  cause  and  its  effect  (p.  326) ;  the  want  of  correspondence,  in 
respect  of  quantity,  between  the  local  and  the  constitutional  phenomena 
(p.  326);  the  seeming  capacity  of  self-augmentation  (p.  327). 

(h)  The  transformation  of  a  morbid  material  is  indicated  by  the 
diversity  of  the  successive  manifestation  of  a  single  and  continuous 
specific  disease.  Thus,  in  syphilis,  the  primary  disease,  if  left  to  its 
unhindered  course,  is  followed,  with  general  regularity,  by  a  series  of 
secondary  and  tertiary  diseases.  The  terms  often  used  would  imply 
that  these  diseases  are  due  to  a  morbid  poison,  which  is,  all  along,  one 
and  the  same.  But,  identity  of  causes  should  be  manifested  in  identity 
of  effects ;  the  succession  of  morbid  processes  proves  a  succession  of 
changes,  either  in  the  agent  poison,  or  in  the  patient.  They  may  be 
in  the  latter  ;  but,  regularly,  they  are  in  the  former :  for,  on  the  whole, 
the  succession  of  secondary  and  tertiary  syphilitic  diseases  is  uniform 
in  even  a  great  variety  of  patients.  We  may,  therefore,  believe,  that 
the  regular  syphilitic  phenomena  depend  on  the  transformations  of  the 
morbid  poison :  their  irregularities,  on  the  peculiarities  of  the  patient, 
whether  natural  or  acquired  from  treatment. 

The  transformation  here  assumed  is  self-probable,  seeing  the  analogy 
of  successive  transformations  in  all  organic  living  materials.  It  is 
nearly  proved  by  the  different  properties,  in  regard  to  communicability, 
of  the  syphilitic  poison  at  different  periods :  in  the  primary  disease 
communicable  by  inoculation,  but  not  through  the  maternal  blood  to 
the  foetus ;  in  the  secondary,  having  these  relations  reversed ;  in  the 
tertiary,  not  at  all  communicable.  In  like  manner,  such  facts  as  that 
the  material  found  in  the  vaccine  vesicle,  on  the  eighth  day,  is  better 
for  fresh  vaccinations  than  that  taken  earlier  or  later,  prove  successive 
transformations, — periods,  we  may  say,  of  development,  maturity,  and 
degeneration,  in  the  material  of  the  virus. 

*  Loc.  cit.  p.  ]59.  I  Lectures  on  Surgical  Pathology,  p.  262. 


IN    THE    BLOOD    AND    TISSUES.  335 

Many  similar  phenomena  of  transformations  in  the  morbid  poisons 
may  be  cited  ;  and  if  it  may  be  accepted  as  a  general  occurrence,  it  will 
explain  many  of  the  phenomena  of  specific  diseases.  The  period  of 
incubation  or  latency  of  a  disease  may  correspond  with  the  transforma- 
tion preceding  the  efiective  state  of  the  morbid  poison,  with  its  periods 
of  development.  The  prodromata,  the  precursive  constitutional  affec- 
tions, and  the  successive  stages  of  the  disease,  indicate  the  continuous 
transformations  and  varying  influences  of  the  same ;  just  as  every 
diflFerence  of  organic  construction  indicates  a  difference  in  the  yet  un- 
formed materials  used  in  it.  The  increasing  disturbance  of  the  general 
health  probably  implies  that  the  morbid  poison  increases  while  being 
transformed ;  that  it  grows  with  its  development.  The  periodicity  of 
all  these  events  (p.  328)  is  a  sign  that  the  transformations  of  morbid 
poisonSj  like  those  of  all  other  materials  in  the  living  body,  are,  in 
ordinary  circumstances,  accomplished  in  definite  times.  The  sequelae 
of  specific  diseases  indicate  yet  further  transformations,^  or,  more  pro- 
bably, that  the  changes  of  the  morbid  poison  have  left  the  blood  in  a 
morbid  state,  through  the  exhaustion  of  some  of  its  natural  constituents,, 
or  through  the  presence  of  some  complemental  material. 

(c)  The  combination  of  a  morbid  poison  with  one  or  more  of  the  nor- 
mal materials  of  the  blood  is  indicated  by  the  fact,  that  when  the  same 
specific  disease,  produced  even  by  the  inoculation  of  the  same  matter, 
affects  many  persons,  it  may  present  in  each  of  them  certain  peculiar 
features.  And  these  personal  peculiarities,  as  they  might  be  called, 
indicate  modified  qualities  of  the  disease ;  not  merely  such  differences 
of  quantity  as  might  be  explained  by  assuming  that  each  person  has, 
in  his  blood,  a  different  quantity  of  such  material  as  may  be  convertible 
into  the  morbid  poison.  Difference  of  quantity  may  explain  (as  Mr. 
Simon  and  Dr.  Carpenter  have  shown)  difference  of  intensity  of  specific 
disease,  and  difference  of  liability  to  epidemic  influence  ;  but  it  does 
not  explain  the  varied  method  of  the  same  disease  in  different  persons. 
For  this,  I  believe,  we  must  assume  that  the.  specific  material  of  each 
disease  may  be,  in  some  measure,  modified  by  its  combination  with  one 
or  more  of  those  normal  materials  of  the  blood  which  have,  in  each 
person,  a  peculiar  or  personal  character  (see  p.  34,  e.  s.) 

By  such  combination,  we  may  best  explain  those  characters  of  specific 
disease,  which  appear  in  its  changes  in  transmission  from  one  person  to 
another  (page  327) :  such  as  the  varieties  of  syphilitic  sores,  and  the 
varieties  of  their  consequences  in  different  persons  inoculated  from  the 
same  source ;  the  change  in  the  form  of  secondary  syphilis  or  of  cancer 
in  transmission  from  parent  to  offspring ;  the  several  peculiarities  in  the 
results  of  the  same  miasm  when  affecting  ordinary  persons,  or  puerperal 
women,  or  those  who  have  survived  injuries. 

A  remarkable  instance,  exemplifying,  I  think,  as  well  the  changes  in 
the  morbid  poison  itself,  as  its  various  effects  on  different  persons,  has 
been  told  me  by  my  friend  Mr.  Huxley.     One  of  the  crew  of  H.  M.  S. 


336         MORBID    MATERIALS    IN    THE     BLOOD    AND    TISSUES. 

Rattlesnake,  after  slightly  wounding  his  hand  with  a  beef  bone,  had 
suppuration  of  the  axillary  lymphatic  glands,  with  which  typhoid  symp- 
toms and  delirium  were  associated,  and  proved  fatal.  His  illness  began 
the  day  after  the  ship  left  Sydney,  where  all  the  crew  had  been  remark- 
ably healthy.  A  few  days  after  his  death,  the  sailor  who  washed  his 
clothes  had  similar  symptoms  of  disease  in  the  axilla,  and,  for  four  or 
five  months,  he  suffered  with  sloughings  of  portions  of  the  areolar  tis- 
sue of  the  axilla,  arm,  and  trunk  on  the  same  side.  Near  the  same 
time,  a  third  sailor  had  diffuse  inflammation  and  sloughing  in  the  axilla; 
and  after  this  "  the  disease  ran,  in  various  forms,  through  the  ship's 
company,  between  thirty  and  forty  of  whom  were  sometimes  on  the  sick- 
list  at  once."  Some  had  diffuse  cellular  inflammation,  some  had  inflam- 
mation of  the  lymphatic  glands  of  the  head,  axilla,  or  lower  extremities ; 
one  had  severe  idiopathic  erysipelas  of  the  head  and  neck  ;  another  had 
phlegmonous  erysipelas  of  the  hand  and  arm  after  an  accidental  wound ; 
others  had  low  fever,  with  or  without  enlargement  of  glands.  "Finally, 
the  disease  took  the  form  of  mumps,  which  affected  almost  everybody 
on  board."  The  epidemic  lasted  from  May  to  July.  The  ship  was  at 
sea  the  whole  time,  and,  in  the  greater  part  of  it,  in  the  intense  cold  of 
a  southern  winter. 

[d]  The  separation  of  the  material  of  a  specific  disease  may,  probably, 
be  accomplished  in  many  different  ways,  and  may  be  regarded  as  the 
final  purpose  (if  we  may  venture  to  trace  one)  of  the  greater  part  of  the 
morbid  process.  It  is  evident  in  the  inoculable  products  of  sores  and 
pustules ;  in  the  infectious  exhalations  of  the  skin,  pulmonary,  and 
other  surfaces  in  the  exanthematous  and  other  fevers ;  in  the  deposits 
in  and  near  gouty  joints.  Analogy  with  these  cases  makes  it,  also, 
probable  that  the  specific  materials  of  several  other  diseases  are  sepa- 
rated from  the  blood  accumulated  at  the  seats  of  the  local  morbid  pro- 
cess ;  whence,  if  no  organisms  incorporating  them  be  constructed,  they 
may  be  reabsorbed  after  transformation.  And  it  is  nearly  certain  that 
the  materials  of  most  specific  diseases  may  be  excreted  with  the  natural 
evacuations  in  the  course  of  the  disease,  and  this,  either  in  their  mature 
state,  or  after  transformation,  or  in  combination  with  the  constituents 
of  specific  medicines. 

The  results  of  such  separation  or  excretion  are,  also,  various.  Some- 
times, it  seems  as  if  the  whole  of  the  morbid  material  were  (after  various 
transformations)  removed,  and  the  blood  left  healthy :  as  in  small-pox, 
vaccinia,  cured  primary  syphilis.  Sometimes  part  of  the  morbid  ma- 
terial, transformed  or  combined,  so  as  to  be  incapable  of  excretion, 
remains  in  the  blood,  and  produces  secondary  phenomena  or  sequelae 
of  the  disease.  Sometimes,  the  production  of  the  morbid  material  con- 
tinues, notwithstanding  the  separation  of  what  is  already  formed;  as  in 
the  increase  of  the  cancerous  diathesis  during  the  growth  of  cancers. 
Generally,  in  whatever  manner  the  separation  be  accomplished,  it  is 
attended  by  such  disturbance  of  the  natural  functions  of  parts,  that 


CLASSIFICATION    OF    TUMOKS.  337 

serious  disease  is  superadded  to  that  which  is  the  more  direct  conse- 
quence of  the  presence  of  the  morbid  material  in  the  blood.  And 
lastly,  a  local  disease  which  owes  its  origin,  and  for  a  time  its  mainte- 
nance, to  a  specific  morbid  condition  of  the  blood,  may  persist  after 
that  condition  has  ceased ;  the  blood  may  regain  its  health  by  the  sepa- 
ration of  the  morbid  material,  but  the  part  diseased  in  the  process  of 
separation  may  so  continue.  Now,  however,  the  disease  may  be  wholly 
local,  and  curable  by  local  treatment. 

Thus  may  the  theory  of  specific  diseases  be  applied  in  explanation  of 
their  phenomena.  I  will  only  add  that,  in  assuming  all  this  of  the 
changes  occurring  in  morbid  materials  in  the  blood,  we  really  assume 
little  more  than  we  believe  of  the  organizable  materials  introduced,  as 
nutriment,  into  the  blood.  If  we  could  trace  these,  in  their  changes, 
first  in  the  chyle  and  blood,  and  then  in  some  complex  tissue,  then  in 
the  lymph  and  blood  again,  and  again  through  the  tissue  of  some  excre- 
tory gland,  we  should  trace  a  career  of  changes  not  less  numerous,  not 
less  definite  in  method  and  in  time,  not  less  influential  in  the  economy, 
than  those  which  I  have  assumed  for  morbid  materials  in  the  blood. 
Only,  the  increase  of  the  morbid  material,  and  the  apparent  indepen- 
dence of  its  changes,  are  not  imitated  in  the  normal  events  of  life. 


LECTURE  XXI. 


CLASSIFICATION   OF   TUMORS. 


The  class  of  diseases  which  includes  the  tumors  may  be  reckoned  as 
a  part  of  the  great  division  named  Hypertrophies  or  Overgrowths.  All 
its  members  consist  in  additions  to  the  organized  materials  of  the  body, 
and  appear  to  be  expressions  of  a  morbid  excess  of  formative  force  ; 
but,  in  the  case  of  each  hypertrophy,  the  mode  is  peculiar  in  which  this 
excess  is  manifested.  If  we  compare  any  tumor  with  one  of  the  hyper- 
trophies that  are  least  morbid,  with  one  of  those,  for  instance,  in  which 
the  excessive  growth  is  adapted  to  some  emergency  of  disease,  as  an  hy- 
pertrophy of  the  heart  is  adapted  to  some  emergency  of  the  circulation, 
we  shall,  I  believe,  always  see  between  them  this  chief  difference  :  that, 
to  whatever  extent  the  adapted  hypertrophy  may  proceed,  the  over- 
grown part  maintains  itself  in  the  normal  type  of  shape  and  structure ; 
while  a  tumor  is  essentially  a  deviation  from  the  normal  type  of  the 
body  in  which  it  grows,  and,  in  general,  the  longer  it  exists  the  wider 
is  the  deviation.  A  striking  illustration  of  this  contrast  may  be  found 
in  some  of  the  cases  of  fibrous  tumors  that  grow  into  the  cavity  of  the 


338  GENERAL  CHARACTERS  OF  TUMORS. 

uterus.*  Such  a  tumor  may  resemble  in  its  tissues  the  substance  of 
the  uterus  itself,  having  well-formed  muscular  and  fibrous  tissues ;  and, 
so  far  as  the  structures  formed  in  excess  are  concerned,  we  might  regard 
the  tumor  as  the  result  of  an  hypertrophy  not  essentially  different  from 
that  which,  at  the  same  time  and  rate,  may  take  place  in  the  uterine 
walls  around  it.  But  an  essential  difference  is  in  this :  the  uterus,  in 
its  growth  around  the  tumor,  maintains  a  normal  type,  though  excited 
to  its  growth,  if  we  may  so  speak,  by  an  abnormal  stimulus  :  it  exactly 
imitates,  in  vascularity  and  muscular  development,  the  pregnant  uterus, 
and  may  even  acquire  the  like  power ;  and  at  length,  by  contractions, 
like  those  of  parturition,  may  expel  the  tumor,  spontaneously  separated. 
But  the  tumor  imitates  in  its  growth  no  natural  shape  or  construction : 
the  longer  it  continues  the  greater  is  its  deformity.  Neither  may  we 
overlook  the  contrast  in  respect  of  purpose,  or  adaptation  to  the  gene- 
ral welfare  of  the  body,  which  is  as  manifest  in  the  increase  of  the  uterus 
as  it  is  improbable  in  that  of  the  tumor. 

Herein  we  seem  to  discern  ah  essential  difference  between  the  over- 
growths of  tumors,  and  those  accomplished  by  any  exercise  of  the 
normal  power  of  nutrition  in  a  part.  This  power,  capable  of  augmented 
exercise  in  any  emergency,  is  yet  not  a  mere  capacity  of  production  ; 
neither  is  it  dependent  upon  circumstances  for  the  fashion  of  its  pro- 
ducts ;  identical  with  that  which  effected  the  development  of  the  germ, 
it  is  equally  bound  to  conformity  with  the  proper  type  of  the  part  or 
species  in  which  it  is  exercised. 

An  equal  contrast  may,  in  general,  be  drawn  between  the  class  of 
diseases  that  include  tumors,  and  all  the  others  that  issue  in  a  morbid 
excess  of  nutritive  formation.  We  may  take,  as  the  example  of  these, 
the  inflammatory  diseases  attended  with  exudation,  and  say  (reserving 
certain  conditions,  p.  295)  that  in  these  there  is  an  excessive  exercise  of 
formative  force — an  hypertrophy.  But  between  such  diseases  and 
tumors  we  shall  rarely  fail  to  observe  the  following  differences :  1st. 
The  accumulation  and  increase  of  lymph  in  inflammation  appears  chiefly 
due  to  the  morbid  state  of  the  parts  at,  or  adjacent  to,  the  place  of  ex- 
udation. We  have,  I  think,  no  evidence  that  the  lymph  of  inflammation 
increases  by  any  inherent  force,  any  attraction  of  self-organizing  mat- 
ter; but  the  increase  of  all,  or  nearly  all,  tumors,  is  "of  themselves  :" 
they  grow  as  parts  of  the  body,  but  by  their  own  inherent  force,  and 
depend  on  the  surrounding  parts  for  little  more  than  the  supply  of 
blood,  from  which  they  may  appropriate  materials.  A  tumor,  there- 
fore, as  a  general  rule,  increases  constantly  ;  an  inflammatory  exudation 
generally  increases  only  so  long  as  the  disease  in  the  adjacent  parts 
continues. 

2d.  The  materials  severally  produced  in  excess,  in  these  two  cases, 

*  Such  as  (e.  g.)  No.  2682  in  the  College  Museum.  Respecting  the  conditions  in  which 
the  changes  in  the  uterus  here  described  are  likely  to  occur,  see  Rokitansky,  Pathologische 
Anatomie,  iii,  546. 


GENERAL    CHARACTERS    OF    TUMORS.  339 

have  different  capacities  of  development.  The  inflammatory  exudation, 
in  whatever  part  it  lies,  has  scarcely  more  than  the  single  capacity  to 
form,  in  the  first  instance,  connective  tissue :  the  material  that  begins 
or  is  added  to  a  tumor  may,  indeed,  assume  this  form,  but  it  may  assume 
any  one  of  several  other  forms. 

But,  3dly,  the  most  striking  contrast  is  in  the  events  subsequent  to 
this  first  organizing  of  the  two  materials.  The  latter  course  of  organ- 
ized inflammatory  exudations,  like  that  of  the  organized  material  for 
repair  after  injuries,  is  usually  one  of  constant  approximation  to  a 
healthy  state.  As  newly-formed  parts,  they  gradually  assimilate  them- 
selves to  the  shape  and  purpose,  if  not  to  the  tissue,  of  the  parts  among 
which  they  lie ;  or  they  are  apt  to  waste,  degenerate,  and  be  removed. 
Their  changes  tend  ever  towards  a  better  state;  so  that,  in  the  whole 
course  of  exudative  inflammatory  diseases,  some  can  see  nothing  but  an 
"  effort  of  nature"  to  avert  or  repair  some  greater  evil.*  It  is  very 
different  with  the  class  of  diseases  to  which  tumors  belong :  it  is  in  their 
very  nature  to  proceed  to  further  and  further  deviation  from  the  proper 
type  of  the  body.  The  structure  of  tumors  may,  indeed,  be  like  that 
of  some  of  the  natural  parts ;  it  may  be  identical  with  that  of  the  part 
in  which  they  lie :  in  this  respect  they  may  be  called  homologous  ;  but, 
considered  in  their  life,  they  are  not  so ;  for,  commonly,  they  are  grow- 
ing while  the  tissues  far  and  near  around  them  are  only  maintaining 
their  integrity,  or  are  even  degenerating,  or  yielding  themselves  to  the 
abnormal  growth. 

I  think  that  it  is  only  in  the  consideration  of  this  activity  and  partial 
independence  of  the  life  of  tumors,  and  of  the  diseases  allied  to  them, 
that  we  shall  ever  discern  their  true  nature.  We  too  much  limit  the 
grounds  of  pathology,  when,  examining  a  tumor  after  removal,  we  only 
now  compare  it  with  the  natural  tissues.  The  knowledge  of  all  its  pre- 
sent properties  may  leave  us  ignorant  of  the  property  which  it  alone,  of 
all  the  components  of  the  body,  had  some  time  ago, — the  property  of 
growing.  And  so,  if  we  can  ever  attain  the  knowledge  of  the  origin  of 
a  tumor,  it  may  avail  little,  unless  it  supply  also  the  explanation  of  its 
progress.  If,  for  example,  what  is  very  improbable  could  be  proved, 
namely,  that  tumors  have  their  origin  in  the  organization  of  extrava- 
sated  blood,  or  of  an  inflammatory  exudation,  still  this  greater  problem 
would  remain  unsolved :  How  or  why  is  it,  that,  in  ordinary  cases, 
these  materials,  when  organized,  graduall3^  decrease,  and  assimilate 
themselves  to  the  adjacent  parts;  while,  in  the  assumed  formation  of 
tumors,  they  gradually  increase,  and  pursue,  in  many  cases,  a  peculiar 
method  of  development  and  growth  ?  Why  is  it  that,  assuming  even  a 
similarity  of  origin,  the  new-formed  part  manifests,  in  the  one  class  of 
cases,  a  continuous  tendency  towards  conformity  with  the  type  of  the 

*  There  are,  indeed,  cases  in  which  organized  lymph  and  scars  continue  to  grow ;  but 
these  are  quite  exceptional,  and  are  to  be  regarded  as  diseases  of  the  same  class  as  tumors, 
peculiar  only  in  respect  of  the  materials  in  which  they  are  manifested. 


340  GENERAL    CHARACTERS     OF    TUMORS. 

body ;  in  the  other,  a  continuous  deviation  from  it  in  shape  and  volume, 
if  not  in  texture  ?  How  is  it  that,  to  take  an  extreme  case,  we  can 
ever  find,  as  in  a  specimen*  at  St.  George's  Hospital,  fatty  tumors  of 
considerable  size  in  the  mesentery  of  a  patient  from  whom,  in  the  ex- 
tremest  emaciation  of  phthisis,  nearly  all  the  natural  fat  was  removed ; 
or,  as  in  a  case  related  by  Schuh,t  huge  lumps  of  fat,  on  the  head, 
throat,  and  chest  of  a  man  whose  abdomen  and  legs  were  extremely 
thin  ? 

I  do  not  pretend  to  answer  these  questions ;  but  I  think  that  in  them 
is  the  touchstone  by  which  we  may  tell  the  value  of  a  pathology  of  this 
great  class  of  diseases.  It  is  not  in  the  likeness  or  in  the  unlikeness  to 
the  natural  tissues  that  we  can  express  the  true  nature  of  tumors  :  it  is 
not  enough  to  consider  their  anatomy ;  their  physiology,  also,  must  be 
studied ;  as  dead  masses,  or  as  growths  achieved,  they  may  be  called 
like  or  unlike  the  rest  of  a  part ;  but,  as  things  growing,  they  are  all 
unlike  it.  It  is,  therefore,  not  enough  to  think  of  them  as  hypertrophies 
or  overgrowths :  they  must  be  considered  as  parts  overgrowing,  and  as 
overgrowing  with  appearance  of  inherent  power,  irrespective  of  the 
growing  or  maintenance  of  the  rest  of  the  body,  discordant  from  its  nor- 
mal type,  and  with  no  seeming  purpose. 

To  all  this,  I  know,  it  may  be  objected  that  tumors,  and  other  like 
growths,  may  cease  to  grow,  or  grow  unequally,  and  yet  be  tumors  still. 
But  this  is  only  in  appearance  opposed  to  what  I  have  said,  which  is  no 
more  than  that  the  best  or  only  time,  in  which  we  may  discern  the  true 
difference  of  these  from  other  growths,  is  the  time  of  their  active  in- 
crease. As  we  can  have  no  complete  idea  of  any  living  thing,  unless 
it  include  the  recognition  of  its  origin,  and  of  its  passage  through  certain 
phases  of  development  and  growth ;  so  must  our  thoughts  of  these  ab- 
normities be  imperfect  or  untrue,  unless  we  have  regard  to  their  de- 
velopment and  growth,  and  maintenance,  as  independent  parts.  But, 
indeed,  the  cessation  of  growth  in  tumors  and  the  allied  diseases  often 
affords  evidences  of  their  peculiar  nature,  confirmatory  of  that  deduced 
from  their  increase.  Such  cessation  may  occur  when  they  have  attained 
a  certain  regular  size ;  as  in  the  painful  subcutaneous  tumors,  the  osse- 
ous tumors  on  the  phalanges  of  great  toes,  and  some  others,  which, 
perhaps  always,  cease  to  grow  when  they  have  reached  a  limit  of  dimen- 
sions that  appears  as  natural  and  constant  for  them  as  the  average 
stature  is  for  the  individuals  of  any  species.  Or,  the  cessation  of  growth 
may  occur  when  the  tumor  degenerates  or  wastes  ;  as  when  a  fibrous 
tumor  calcifies,  or  when  a  mammary  grandular  tumor  is  absorbed.  But 
it  is  to  be  observed  that  these  events  are,  or  may  be,  as  irrespective  of 
the  nutrition  of  all  the  rest  of  the  body,  as  the  development  and  growth 
of  the  tumor  were  ;  and  that,  except  in  the  comparatively  rare  event  of 
the  absorption  of  a  tumor,  there  is,  in  no  case,  an  indication  of  return 

*  Y.  71,  Museum  of  St.  George's  Hospital. 

f  Die  Erkenntniss  der  Pseudoplasp.  101.     Wien,  1851. 


GENERAL     CHARACTERS     OF    TUMORS.  341 

to  the  normal  type  or  condition  of  the  body  :  there  is  no  improvement, 
as  in  the  organized  lymph  formed  in  the  inflammatory  process,  no  adap- 
tation to  purpose,  no  assumption  of  a  more  natural  shape.  In  all  these 
events,  therefore,  as  well  as  in  their  growth,  the  nearly  independent 
nature  of  the  tumor  is  shown  :  while  forming  part  of  the  body,  and 
borrowing  from  it  the  apparatus  and  the  materials  necessary  to  its  life 
the  tumor  grows  or  maintains  itself,  or  degenerates,  according  to  pecu- 
liar laws. 

The  characters  of  which  I  have  been  speaking  belong  to  a  larger 
number  of  abnormities  than  are  usually  called  tumors :  they  belong,  in- 
deed, to  a  large  class,  of  which  tumors  form  one  part  or  section,  while 
the  other  is  composed  of  certain  morbid  enlargements  of  organs,  by  what 
is  regarded  as  merely  hypertrophy  ;  such  as  that  of  the  prostate,  the 
thyroid  gland,  and  others.*  Kow  the  distinction  between  these  two 
divisions  of  the  class  must,  I  believe,  be  an  arbitrary  one  ;  for  the  two 
are  so  little  unlike,  that,  really,  it  is  in  these  hypertrophies  of  glands 
that  we  may  hope  to  find  the  truest  guidance  to  an  insight  into  the 
nature  of  tumors. 

In  speaking  of  cysts  from  the  walls  of  which  vascular  growths  may 
spring  and  fill  their  cavities,  I  shall  have  to  describe  that  these  intra- 
cystic  growths  are,  in  their  best  state  of  structure,  close  imitations  of 
the  gland  in  which  they  occur.  In  relation  to  tumors,  the  most  instruc- 
tive examples  of  this  fact  are  in  the  cystic  tumors  of  the  breast,  of  which 
the  general  structure  has  been  especially  illustrated  by  Dr.  Hodgkin 
and  Sir  B.  C.  Brodie,  and  the  microscopic  characters  by  M.  Lebert  and 
Mr.  Birkett.  Among  these,  a  series  of  specimens  in  the  Museumf  may 
illustrate  every  stage  of  the  transition,  from  the  simple  cyst,  to  the  cyst 
so  filled  with  gland  substance  as  to  form  a  solid  tumor, — the  chronic 
mammary,  or  mammary  glandular  tumor.  Now  a  near  parallel  with  the 
history  of  these  mammary  tumors  is  presented  by  the  observations  of 
FrerichsJ  and  Rokitansky§  on  the  intra-cystic  groAvths  which  occur 

*  The  class  may  seem  to  include,  also,  those  abnormal  states  of  the  fcEtns  which  are  at- 
tended with  excessive  growth  or  development  of  organs  or  members,  yet  cannot  be  ascribed 
to  a  fusion  of  two  germs;  and,  indeed,  in  the  case  of  certain  bony  growths,  the  line  cannot 
be  drawn,  without  artifice,  between  monstrosities  by  excess  and  tumors.  But,  in  the  large 
majority  of  cases,  there  are  sufficient  characters  of  distinction  between  them;  for,  1st,  the 
congenital  excesses  of  development  present  a  more  complex  structure,  and  are  more  con- 
formed to  the  plan  and  construction  of  the  body,  than  anything  that  can  be  reasonably  called 
a  tumor.  And  if  it  be  said  that  this  higher  organization  is  no  more  than  is  consistent  with 
the  period  of  formation,  which  is  in  embryo-life,  when  the  force  of  development  is  greatest, 
then,  2dly,  we  may  note  this  difference  :  that  the  congenital  excesses  are  usually  limited  for 
their  increase  to  the  period  of  natural  growth  of  the  body.  They  commonly  cease  to  grow 
when  or  before  the  body  has  attained  its  full  stature;  they  conform  to  its  methods  and  times 
of  development,  growth,  and  decay. 

t  Mus.  Coll.  Surg.,  Nos.  168,  169,  170,  172,  &c. 

J  Ueber  Gallert-oder  Colloid-geschwiilste.     Gottingen,  1847. 

I  Zur  Anatomic  des  Kropfes  ;  and  Ueber  die  Cyste,  in  the  Denkschr.  der  K.  Akademie 
der  Wissenschaften,  Wien,  1849. 


342  DISTINCTIONS    OF    INNOCENT 

within  the  substance  of  enlarging  thyroid  glands,  i.  e,,  of  increasing 
bronchoceles.  In  these,  masses  of  new-formed  thyroid  gland-tissue  are 
found  imbedded,  and  inclosed  in  coverings  or  capsules  of  connective  tis- 
sue, within  the  proper  though  increased  substance  of  the  gland.  In  like 
manner,  as  Rokitansky  first  showed,  it  is  not  unusual,  in  enlargements 
of  the  prostate  gland,  to  find  distinct  masses  of  new  structure  imitating 
that  of  the  prostate,  which  lie  imbedded  and  incapsuled  in  the  proper 
substance  of  the  gland.  Moreover  (and  here  is  a  closer  contact  between 
these  hypertrophies  and  tumors),  these  growths  of  new  gland-tissue  may 
appear,  not  only  in  the  substance  of  the  enlarging  thyroid  and  prostate 
glands,  but  external  to  and  detached  from  the  glands.  Such  outlying 
masses  of  thyroid  gland  are  not  rare  near  bronchoceles ;  lying  by  them 
like  the  little  spleens  one  often  sees  near  the  larger  mass.  Near  the 
enlarged  prostate,  similar  detached  outlying  masses  of  new  substance, 
like  tumors  in  their  shape  and  relations,  and  like  prostate  gland  in  tis- 
sue, may  be  sometimes  found.  ,  A  very  large  and  remarkable  specimen 
of  the  kind  was  sent  to  me  by  Mr.  Wyman.*  It  was  taken  from  a  man, 
64  years  old,  who,  for  the  last  four  years  of  his  life,  was  unable  to  pass 
his  urine  without  the  help  of  the  catheter.  He  died  with  bronchitis ;  and 
a  tumor,  measuring  2|  inches  by  IJ,  was  found,  as  Mr.  Wyman  de- 
scribed it,  "  lying  loose  in  the  bladder,  only  connected  to  it  by  a  pedicle, 
moving  on  this  like  a  hinge,  and,  when  pressed  forwards,  obstructing  the 
orifice  of  the  urethra."  Now,  both  in  general  aspect  and  in  micro- 
scopic structure,  this  tumor  is  so  like  a  portion  of  enlarged  prostate 
gland,  that  I  know  no  character  by  which  to  distinguish  them. 

The  relation  of  these  new-formed  isolated  portions  of  thyroid  or  pro- 
state gland  is  so  intimate,  on  the  one  side,  to  admitted  tumors,' such  as 
the  chronic  mammary,  and,  on  the  other  side,  to  the  general  hypertro- 
phies of  the  glands,  that  we  cannot  dissociate  these  diseases  without 
great  violence  to  nature.  Clearly  these  are  all  essentially  the  same 
kind  of  disease  :  yet,  to  call  them  all  "tumors"  would  be  to  do  as  much 
violence  to  the  conventional  use  of  terms  which  have  become  not  merely 
the  expressions,  but  the  guides,  of  our  thoughts.  The  best  course  seems 
to  be  to  make  an  arbitrary  division  of  this  group.  In  accordance,  then, 
with  the  arbitration  of  custom,  we  may  assign  the  name  of  tumors  to 
such  examples  of  these  morbid  growths  or  growing  parts,  as,  1st,  are 
isolated  from  the  surrounding  parts  by  distinct  investing  layers  of 
tissue  ;  or,  2dly,  though  continuous  with  the  natural  parts,  are  abruptly 
circumscribed  in  the  greater  part  of  their  extent;  or,  3dly,  are  formed  of 
new  materials  infiltrated  and  growing  in  the  interstices  of  natural  parts. 

If  the  group  of  what  are  to  be  called  tumors  may  be  thus  inclosed, 
we  may  next  proceed  to  divide  it  into  smaller  parts.     And,  first,  it 

*  The  specimen  is  in  the  Museum  of  St.  Bartholomew's  Hospital.  A  remarkable  tumor 
of  the  same  kind,  but  imbedded  in  the  substance  of  the  prostate,  is  in  the  Museum  of  the 
Middlesex  Hospital. 


AND    MALIGNANT    TUMORS.  343 

seems  proper  to  divide  tumors  into  two  principal  divisions,  according  as 
they  may  be  named  innocent  or  malignant,  and  a  third  intermediate 
group  of  such  as  may  be  named  recurrent.  I  would  employ  the  terms 
innocent  or  malignant  still,  because,  though  not  free  from  objections, 
they  imply  a  more  natural  and  a  less  untrue  division  than  any  yet 
invented  to  replace  them.  The  distinction  between  innocent  and  ma- 
lignant tumors  is  probably  one,  not  of  mere  visible  structure,  but  of 
origin  and  vital  properties ;  it  is,  therefore,  less  falsely  expressed  by 
terms  implying  quality  of  nature  than  by  such  as  refer  to  structure 
alone. 

The  chief  distinctions  are  to  be  traced  in  certain  characters  which,  in 
the  malignant  tumors  or  cancers  (for  these  terms  are  synonymous),  are 
superadded  to  those  already  cited  as  belonging  to  the  whole  class. 

And,  1st,  the  intimate  structure  of  malignant  tumors  is,  usually,  not 
like  that  of  any  of  the  fully  developed  natural  parts  of  the  body,  nor 
like  that  which  is  formed  in  a  natural  process  of  repair  or  degeneration. 

Many  of  the  cells  of  cancers,  for  example,  may  be  somewhat  like 
gland-cells,  or  like  epithelium-cells ;  yet  a  practised  eye  can  distinguish 
them,  even  singly.  And  much  more  plainly  their  grouping  distin- 
guishes them ;  they  are  heaped  together  disorderly,  and  seldom  have 
any  lobular  or  laminaii  arrangement,  such  as  exists  in  the  natural  glands 
and  epithelia,  or  in  the  innocent  glandular  or  epithelial  or  epidermal 
tumors.  These  innocent  tumors  are  really  imitations,  so  far  as  their 
structure  is  concerned,  of  the  natural  parts ;  and  the  existence  of  such 
imitations  in  any  tumors  makes  the  diversity — the  heterology,  as  it  is 
called — of  the  malignant  tumors,  appear  more  evident. 

Still,  this  rule  of  dissimilarity  of  structure  in  malignant  tumors  is 
only  general.  The  other  properties  of  malignancy  may  be  sometimes 
observed  in  tumors  that  have,  apparently,  the  same  structure  as  those 
that  are  generally  innocent.  I  shall  have  to  refer  to  cases  of  fibrous 
tumors  which,  in  every  respect  of  structure,  were  like  common  fibrous 
tumors,  and  yet  returned  after  removal,  and  ulcerated,  with  infection 
of  adjacent  parts,  and  appeared  in  internal  organs.  These,  with  some 
others,  must  be  regarded  as  malignant,  though  in  structure  resembling 
innocent  tumors  and  natural  tissues.  On  the  other  hand,  there  are 
some  innocent  cartilaginous  tumors,  with  structures  as  difi'erent  from 
those  that  exist  in  our  natural  tissues,  as  cancer-cells  are  from  gland- 
cells,  or  from  epithelial- cells.  The  two  sets  of  cases,  though  both  be 
exceptional,  supply  sufficient  grounds  for  not  preferring  such  terms  as 
"  homologous"  and  "heterologous"  before  "innocent"  and  "malig- 
nant," if  the  former  are  meant,  as  they  commonly  are,  to  apply  to  the 
structure  of  the  several  growths. 

2d.  Malignant  growths  may  have  the  character  of  infiltrations ;  i.  e. 
their  elementary  structures  may  be  inserted,  infiltrated,  or  diffused  in 
the  interspaces  and  cavities  of  the  tissues  in  which  they  lie.  Thus,  in 
its  early  state,  a  malignant  tumor  may  comprise,  with  its  own  proper 


344  DISTINCTIONS    OF    INNOCENT 

elements,  those  of  the  organ  in  which  it  is  formed  ;  and  it  is  only  in  its 
later  life  that  the  elements  of  the  tissue  or  organ  disappear  from  it, 
gradually  degenerating  and  being  absorbed,  or,  possibly,  yielding  them- 
selves as  materials  for  its  growth.* 

Thus,  a  hard  cancer  of  the  mammary  gland  includes  in  its  mass  a 
part,  or  even  the  whole,  of  the  gland  itself,  as  if  there  were  only  a  con- 
version of  the  gland-tissue :  and  one  may  find,  within  the  very  sub- 
stance of  the  cancer,  the  remains  of  the  lactiferous  tubes  involved  in 
it,  and,  with  the  microscope,  may  trace  in  it  the  connective  tissue  that 
separated  the  gland-lobes,  and  the  degenerate  elements  of  the  epithelial 
contents  of  the  tubes  and  acini.  But  among  all  these  lie  the  proper 
cells  of  the  cancerous  growth,  and  these  usually  increase  while  the 
original  structures  of  the  gland  decrease.  So,  too,  in  medullary  cancer- 
ous disease  of  the  uterus,  the  uterus  itself,  or  part  of  it,  is  in  the 
tumor,  and  gradually  wastes,  while  the  medullary  matter,  diffused  or 
infiltrated  in  it,  is  growing. 

The  malignant  growths  may,'  I  say,  thus  appear  as  infiltrations ;  but 
they  are  not  always  so.  Thus,  though  the  hard  cancer  of  the  breast 
is,  commonly  or  always,  an  infiltration  of  cancerous  substance  in  and 
among  the  proper  structures  of  the  gland,  yet  the  hard  cancer  of  the 
bones  is  often  a  distinct  tumor,  such  as  has  no  mixture  of  bone  in  it, 
and  may  be  enucleated  from  the  cavity  or  shell  of  bone  in  which  it  lies. 
So,  too,  while  the  medullary  cancer  of  the  uterus  plainly  consists  in  an 
infiltration  or  insertion  of  new  material  in  the  substance  of  the  organ, 
that  of  the  breast  is  usually  a  separate  tumor,  and  altogether  discon- 
tinuous from  the  surrounding  parts. f 

Many  other  instances  of  similar  contrast  might  be  cited ;  still  the 
fact  that  their  elementary  structures  may  be  thus  infiltrated  in  the  tis- 
sues they  afi"ect  is  a  characteristic  of  malignant  tumors.  I  think  it  is 
rarely  imitated  in  cases  of  innocent  tumors. 

3d.  It  is,  also,  generally  characteristic  of  malignant  tumors  that  they 
have  a  peculiar  tendency  to  ulcerate,  their  ulceration  being  preceded 
by  softening.  One  can,  indeed,  in  this  particular,  only  observe  a 
graduated  difference  between  the  innocent  and  the  malignant  diseases  ; 
for  certain  innocent  tumors,  if  they  groAv  very  rapidly,  are  apt  very 
rapidly  to  decay ;  and  they  may  suppurate  and  discharge  their  ichor 
and  debris  with  foul  and  dangerous  ulceration.  Thus  the  quickly- 
growing  cartilaginous  tumors  may  imitate,  in  these  respects,  malignant 
growths ;  so  may  large  fibrous  tumors  when  they  soften  and  decay.     Or, 

*  See,  on  this  last-mentioned  point,  Rokitansky,  Pathol.  Anatomie,  i,  121,  If,  in  such  a 
case,  the  removal  of  the  original  textures  be  quicker  or  more  considerable  than  the  produc- 
tion of  the  new  morbid  substance,  there  may  be  no  swelling  or  visible  tumor ;  yet,  since  the 
new  material  increases,  the  essential  character  of  a  growth  is  observed.  Such  growth 
v^ithout  swelling  is  often  noticed  in  hard  cancers  of  the  breast  and  of  the  bones. 

f  Nos.  2787,  2796,  and  others  in  the  College  Museum  ;  and  Nos.  15  in  Ser.  32,  and  28  in 
Ser.  35,  of  that  of  St.  Bartholomew's,  illustrate  these  contrasts.  On  the  difference  between 
infiltrations  and  outgrowths,  see  p.  387. 


AND    MALIGNANT    TUMORS.  -    345 

ao-ain,  when  an  innocent  tumor  grows  more  rapidly  than  the  parts  over 
it  can  yield,  they  may  waste  and  ulcerate,  and  allow  it  to  protrude  ; 
and  it  may  now  itself  ulcerate,  and  look  very  like  malignant  dis- 
ease. This  may  be  seen  in  the  protruding  fibrous  tumors  that  ulce- 
rate and  bleed  ;  or,  in  a  more  striking  manner,  in  the  protruding  vas- 
cular growths  that  have  sprung  up  in  the  cystic  tumors  of  the  breast. 
Or,  once  more,  the  characters  of  readiness  to  ulcerate  may  be  imitated 
by  innocent  tumors  after  injuries,  or  in  exposure  to  continued  irrita- 
tion ;  for  they  resist  these  things  with  less  force  than  the  similar  natu- 
ral parts  do.  Hence,  sloughing  and  ulcerating  fibrous,  erectile,  and 
other  tumors,  have  been  often  thought  cancerous,  and  so  described. 

The  respective  tendencies  to  ulcerate  can,  therefore,  be  counted  only 
as  constituting  differences  of  degree  between  the  innocent  and  malig- 
nant tumors.  We  may  speak  of  a  liability  in  the  one  case,  of  a  prone- 
ness  in  the  other. 

4th.  The  softening  that  often  precedes  the  ulceration  of  malignant 
growths,  can  hardly  be  considered  separately  from  the  minute  account 
of  their  structure.  I  therefore  pass  it  by,  and  proceed  to  their  fourth 
distinctive  character,  which  is  to  be  noticed  in  the  modes  of  their  ul- 
ceration. 

This  is,  that  the  ulcer  which  forms  in,  or  succeeds,  a  malignant 
growth,  has  no  apparent  disposition  to  heal ;  but  a  morbid  substance, 
like  that  of  which  the  original  growth  was  composed,  forms  the  walls  or 
boundaries  of  the  ulcer ;  and  as  this  substance  passes  through  the  same 
process  of  ulceration  which  the  primary  growth  passed  through,  so  the 
malignant  ulcer  spreads  and  makes  its  way  through  tissues  of  all  kinds. 

In  contrast  with  this  character  of  malignant  growths,  it  is  observable 
that  beneath  and  around  an  ordinary  ulcer  of  the  natural  tissues,  or  of 
an  innocent  tumor,  we  find  the  proper  tissues  unchanged ;  or,  perhaps, 
infiltrated  and  succulent  with  recent  lymph,  or  the  materials  for  repair  ; 
or  somewhat  indurated  with  lymph  already  organized.  The  base  and 
margins  of  a  cancerous  ulcer  are  themselves  also  cancerous :  those  of  a 
common  ulcer  are  infiltrated  with  only  reparative  or  inflammatory 
material.  In  like  manner,  if  ulceration  extend  through  an  innocent 
growth,  it  may  destroy  it  all,  and  no  similar  growth  will  form  in  the 
adjacent  parts,  replacing  that  which  has  been  destroyed ;  but,  in  the 
ulceration  of  cancer,  while  the  cancerous  matter  is  being  constantly 
discharged,  by  sloughing  or  ulceration,  from  the  surface,  new  matter 
of  the  same  kind,  and  in  more  abundance,  is  being  formed  at  some  dis- 
tance from  the  surface ;  so  that,  in  a  section  through  an  ulcerated 
cancer,  one  does  not  arrive  at  healthy  tissues  till  after  passing  through 
a  stratum  of  cancer. 

5th.  Malignant  tumors  are,  again,  characterized  by  this  :  that  they 
not  only  enlarge,  but  apparently  multiply  or  propagate  themselves ;  so 
that,  after  one  has  existed  for  some  time,  or  has  been  extirpated,  others 

23 


346  DISTINCTIONS     OF    INNOCENT 

like  it  grow,  either  in  widening  circles  round  its  seat,  or  in  parts  more 
remote. 

Mere  multiplicity  is  not  a  distinctive  character  of  malignant  diseases  ; 
for  many  innocent  tumors  may  he  found  in  the  same  person.  But  in 
the  conditions  and  circumstances  of  the  multiplicity  there  are  charac- 
teristic differences.  Thus,  when  many  innocent  tumors  exist  in  the 
same  person,  they  are  commonly,  or  always,  all  in  one  tissue.  A  man 
may  have  a  hundred  fatty  tumors,  but  they  shall  all  be  in  his  subcu- 
taneous fat :  many  fibrous  tumors  may  exist  in  the  same  uterus,  but  it 
is  so  rare,  that  we  may  call  it  chance,  if  one  be  found  in  any  other  part 
in  the  same  patient :  so,  many  cartilaginous  tumors  may  be  in  the  bones 
of  the  hands  and  feet,  but  to  these,  or  to  these  and  the  adjacent  bones, 
they  are  limited. 

There  is  no  such  limitation  in  the  cases  of  multiplicity  of  malignant 
tumors.  They  tend  especially  to  afi"ect  the  lymphatics  connected  with 
the  part  in  which  they  first  arise :  but  they  are  not  limited  to  these.- 
The  breast,  the  lymphatics,  the  skin  and  muscles,  the  liver,  the  lungs, 
may  be  all,  and  at  once,  the  seats  of  tumors.  Indeed  (and  here  is  the 
chief  contrast),  it  is  more  common  to  find  the  many  malignant  tumors 
scattered  through  several  organs  or  tissues  than  to  find  them  limited 
to  one.* 

Moreover,  if  there  be  a  multiplicity  of  innocent  tumors,  they  have 
generally  a  contemporary  origin,  and  all  seem  to  make  (at  least  for  a 
time)  a  commensurate  progress.  But  the  more  ordinary  course  of 
malignant  tumors  is,  that  one  first  appears,  and  then,  after  a  clear 
interval  of  progress  in  it,  others  appear ;  and  these  are  followed  by 
others,  which,  with  an  accelerating  succession,  spring  up  in  difi"erent 
parts. 

6th,  A  sixth  distinctive  character  of  malignant  tumors  is  that,  in 
their  multiplication,  as  well  as  in  their  progress  of  ulceration,  there  is 
scarcely  a  tissue  or  an  organ  which  they  may  not  invade. 

In  regard  to  their  multiplicity,  I  have  just  illustrated  their  contrast 
in  this  point  with  the  innocent  tumors ;  and  a  similar  contrast  is  as 
obvious  in  the  characters  of  the  ulcers.  It  is  seldom  that  a  common 
ulcer  extends,  without  sloughing,  from  the  tissues  it  has  first  afi'ected 
into  any  other ;  rather,  as  a  new  tissue  is  approached,  it  is  thickened 
and  indurated,  as  if  to  resist  the  progress  of  the  ulcer.  But  before  a 
cancerous  ulcer  the  tissues  in  succession  all  give  way,  becoming  first 
infiltrated,  and  then,  layer  after  layer,  degenerating  and  ulcerating 
away  with  the  cancerous  matter. 

One  may  see  this  very  well  in  bones.     Specimens  are  to  be  found  in 

*  A  case  quoted  in  the  Assoc.  Med.  Jal.  Nov.  30,  1855,  from  the  practice  of  Dr.  R.  W. 
Smith,  oifers  a  remarkable  exception  to  this  rule.  A  woman,  with  obsolete  scirrhus  cancer 
of  the  breast,  had  secondary  scirrhus  in  nearly  every  part  of  the  skeleton,  and  scarcely  a 
trace  of  it  in  any  other  structure. 


AND     MALIGNANT    TUMORS.  347 

nearly  all  Museums,  of  tibiae  (for  example)  on  the  fi-ont  surfaces  of 
which  new  bone  is  formed,  in  a  circumscribed  round  or  oval  layer,  a 
line  or  two  in  thickness.  This  bone,  which  is  compact,  hard,  smooth, 
and  closely  united  with  the  shaft  beneath  it,  was  formed  under  an  old 
ulcer  of  the  integuments  of  the  shin.  But,  on  the  other  side,  specimens 
are  found,  which  show  that  when  a  cancerous  ulcer  reaches  bone,  at 
once  the  bone  clears  away  before  it ;  and  a  cavity  with  abrupt,  jagged, 
eaten-out  edges,  tells  the  rapid  work  of  destruction.*  Neither  are 
specimens  rare,  showing  the  progressive  destruction  of  more  various 
tissues  ;  such  as  a  cancer  of  the  scalp  making  way  by  ulceration  through 
the  pericranium,  skull,  and  dura  mater,  and  then  penetrating  deeply 
into  the  brain  ;f  or  one  in  the  integuments  of  the  shin  going  right 
through  the  tibia,  and  deep  into  the  muscles  of  the  calf.| 

Such  are  the  general  characters  of  malignant  tumors.  Those  of  in- 
nocent ones  are  their  opposites  or  negatives.  Thus  :  innocent  tumors 
have  not  a  structure  widely  different  from  that  of  a  natural  tissue ;  they 
do  not  appear  as  infiltrations  displacing  or  overwhelming  the  original 
tissues  of  their  seat ;  they  do  not  show  a  natural  proneness  to  ulcera- 
tion :  nor  is  the  ulceration,  which  may  happen  in  one  through  injury 
or  disease,  prone  to  extend  into  the  adjacent  parts :  they  do  not  appear 
capable  of  multiplying  or  propagating  themselves  in  distant  parts :  they 
do  not  grow  at  the  same  time  in  many  different  tissues. 

Of  recurrent  tumors  the  chief  distinctive  characters  are  that,  like 
innocent  tumors,  their  structures  resemble  those  of  natural  tissues,  but 
only  in  a  rudimental  state,  or  in  conditions  that  may  be  likened  to 
malformations :  that  they  do  not  appear  as  infiltrations ;  that  their 
ulceration,  to  which,  however,  they  are  more  prone  than  most  innocent 
tumors,  is  not  apt  to  extend  into  adjacent  parts :  but  that,  like  malig- 
nant tumors,  they  do  sometimes  appear  in  organs  'distant  from  their 
first  seat,  and  are  exceedingly  prone  to  be  repeatedly  formed  after 
complete  extirpation. 

Now,  the  distinctive  value  of  each  of  these  characteristics  of  malig- 
nant disease  may  be  depreciated :  indeed,  I  have  myself  lowered  it,  by 
showing  that  each  of  them  may  be  absent  in  tumors  having  all  the 
other  features  of  malignancy,  and  that  certain  of  them  may  be  observed 
occasionally  in  tumors  that  in  other  respects  appear  non-malignant. 
But  objections  against  each  character  separated  from  the  rest  are  of 
little  weight  against  the  total  value  of  all  these  characters  of  malig- 
nancy, or  of  a  majority  of  them,  concurrent  in  one  case.  Similar 
objections  might  be  made  against  even  the  classifications  of  natural 
history :  and  none  but  such  as  are  disposed  to  cavil  at  all  nosology, 
could  fail,  in  watching  a  series  of  cases  of  tumors  through  many  years, 

*  In  the  College  Museum,  Nos.  3082-3-3  A;  3267-8,  and  many  others,  illustrate  these 
points. 

f  Museum  of  St.  Bartholomew's,  vi,  57. 
J  Museum  of  the  College  of  Surgeons,  232. 


348  DISTINCTIONS    OF    INNOCENT 

to  observe  that  the  great  majority  of  them  could  be  classed  according 
as,  in  their  course,  they  did  or  did  not  present  the  characters  that  I 
have  enumerated.  Some  cases  would  be  found  in  which  one  or  two  of 
the  signs  might  be  wanting,  or,  if  I  may  so  speak,  misplaced ;  but, 
putting  these  aside,  as  exceptions  to  be  regulated  by  future  inquiry, 
and  looking  broadly  at  the  whole  subject,  no  one  could  doubt  that  this 
division  of  tumors  into  innocent  and  malignant  may  be  justly  made, 
and  that  the  outward  marks  by  which  they  are  discriminated  are  ex- 
pressions of  real  diiferences  in  their  properties  and  import. 

In  what  these  differences  may  consist  I  shall  not  discuss  till  I  have 
completed  my  account  of  each  kind  of  tumor.  For  the  present  I  will 
say  only,  that  I  think  malignant  tumors  are  local  manifestations  of 
some  specific  morbid  states  of  the  blood ;  and  that  in  them  are  incor- 
porated peculiar  morbid  materials  which  accumulate  in  the  blood,  and 
which  their  growth  may  tend  to  increase.  All  their  distinctive  charac- 
ters are,  I  think,  consistent  with  this  view :  and  the  absence  of  the 
characters  in  innocent  tumors  may  lead  us  to  believe  that  they  are 
usually  local  diseases,  the  result  of  some  inexplicable  error  of  nutrition 
in  the  part  that  they  affect,  and  only  in  the  same  measure  dependent 
on  the  state  of  the  blood  as  are  the  natural  tissues,  which  require,  and 
may  be  favored  by,  the  presence  of  their  appropriate  materials  of  nu- 
trition. Or,  when,  as  sometimes  happens,  an  innocent  tumor  begins  its 
growth  during,  or  soon  after,  some  general  disease,  we  may  suppose 
that  it  owes  its  first  formation  to  an  abnormal  condition  of  the  blood ; 
but  that,  when  the  blood  recovers  its  health,  the  tumor  subsists  or 
grows  on  the  nourishment  supplied  by  the  normal  materials  of  the 
blood.  Instances  of  tumors  thus  constitutional  in  their  origin,  but 
subsisting  as  local  diseases,  will  be  mentioned  in  the  general  history  of 
cancers. 

It  may  be  best  to  speculate  no  further,  either  on  this  point,  or  on 
the  origin  or  determining  causes  of  tumors.  I  could  speak  certainly 
of  very  little  connected  with  these  points,  unless  it  were  of  the  error  or 
insufficiency  of  all  the  hypotheses  concerning  them  that  I  have  proposed 
to  myself,  or  have  read  in  the  works  of  others.  One  of  these  alone  seems 
to  need  disproof;  namely,  that  tumors,  whether  innocent  or  malignant, 
are  due  to  the  organization  of  effused  blood,  or  of  some  inflammatory 
or  other  exudation,  or  of  the  material  of  repair.  The  great  objections 
to  this  view  are  as  follows ;  1.  It  is  an  almost  infinitely  small  propor- 
tion of  injuries  that  are  followed  by  the  growth  of  tumors.  2.  In  a 
large  majority  of  cases  of  tumor,  no  injury  or  previous  local  disease 
is  assigned,  even  by  the  patients,  as  the  cause  of  the  growth.  In  200 
cases,  taken  indiscriminately  from  those  I  have  lately  recorded,  no 
local  cause  whatever  could  be  assigned  for  the  growth  of  155  tumors, 
of  which  64  were  innocent  and  91  malignant ;  of  the  remaining  45,  re- 
ferred by  the  patients  to  previous  injury  or  disease  of  the  part,  15  were 
innocent  and  30  malignant  tumors.     3.  Blood  extravasated,  and  the 


AND    MALIGNANT    TUMORS.  349 

products  of  the  inflammatory  and  reparative  processes,  are  not  indif- 
ferent materials,  such  as  would  pursue  this  or  that  direction  of  develop- 
ment, according  to  chance,  or  some  imaginary  influence  exercised  on 
them.  They  have  a  proper  tendency  to  assume  the  form  of  connective, 
or  osseous  tissue.  They  do  not  become,  when  their  history  can  be 
traced,  either  fatty,  or  perfectly  cartilaginous,  or  glandular  tissue,  such 
as  we  find  in  tumors.  4.  No  intermediate  conditions  have  been  yet 
found  between  blood,  or  lymph,  and  a  tumor.  And,  lastly,  all  the 
facts  relating  to  injuries,  as  favoring,  or  determining,  the  growth  of 
tumors,  are  explicable  on  the  supposition  that  the  injury  impairs  for 
a  time  the  nutrition  of  a  part,  and  diminishes  its  power  of  excluding 
abnormal  methods  of  nutrition. 

Narrowing,  now,  the  objects  of  consideration  to  the  innocent  tumors 
alone,  I  will  speak  very  briefly  of  their  classification. 

A  first  subdivision  of  them  may  be  made,  according  to  the  usual 
arrangement,  into  the  cysts,  or  cystic  tumors,  and  the  solid  tumors. 
There  are,  indeed,  not  a  few  instances  in  which  the  two  divisions  over- 
lap, or  are  confused.  Thus,  on  the  one  side,  in  cases  to  which  I  have 
already  referred,  a  solid  growth  may  spring  from  the  inner  walls  of  a 
cyst,  and,  enlarging  more  rapidly  than  the  walls  do,  may  fill  the  cavity, 
and  come  in  contact  and  unite  with  the  walls  ;  and  thus  may  be  traced 
a  complete  series  of  gradations  from  the  cystic  to  the  solid  tumor. 
On  the  other  hand,  cysts  may  be  formed  within  solid  tumors,  and,  in- 
creasing more  rapidly  than  the  solid  structure,  may  reduce  it  to  scarcely 
more  than  a  congeries  of  cysts,  or  to  one  great  cyst.  Such  changes 
are  illustrated  sometimes  in  fibrous  tumors  of  the  uterus  ;  and  I  think, 
also,  in  the  tumors  which  Sir  Astley  Cooper  called  "  hydatid  disease  " 
of  the  testicle. 

But  though  there  are  these  instances  of  confusion,  yet  the  division 
is  very  convenient,  and  is  probably  deeply  and  well  founded. 

Next,  among  cysts,  some  are  filled  with  a  simple  fluid,  containing  no 
organized  matter,  and  resembling  one,  or  other,  of  the  fluids  of  serous 
cavities.  These  may  be  called  simple  or  barren,  or,  in  most  instances, 
serous  cysts. 

Other  cysts  contain  organized  substances,  and  may  be  named,  as  a 
group,  proliferous ;  and  the  several  members  of  the  group  may  be  de- 
scribed, according  to  their  contents,  as  glandular,  cutaneous,  sebaceous, 
dental,  and  the  like. 

Of  the  solid  innocent  tumors,  no  method  of  arrangement  at  present 
appears  reasonable  but  the  old  one,  which  is  founded  on  their  likeness 
to  the  natural  tissues.  On  this  ground  they  may  be  arranged  in  the 
following  divisions,  with  names,  as  speciflc  names,  expressing  their  seve- 
ral resemblances, — viz.,  fatty,  fibro-cellular,  fibrous,  fibroid,  and  fibro- 
nucleated,  cartilaginous,  myeloid,  osseous,  glandular,  and  vascular  or 
erectile.  And,  again,  under  each  of  these  may  be  arranged  certain 
varieties,  including  instances  that,  in  some   uniform  manner,   deviate, 


350  DISTINCTIONS    OF    INNOCENT 

without  quite  departing,  from  the  usual  characters  ;  as  the  fibro-cjstic, 
fibro-calcareous,  and  other  varieties  of  the  j&brous  tumors. 

In  each  assumed  kind  or  group  of  these  solid  tumors,  moreover,  we 
must  make  a  division,  according  to  their  modes  of  growth,  and  of  con- 
nection with  the  adjacent  parts.  Some  among  them  are  only  inter- 
mediately connected  with  the  adjacent  parts  ;  a  layer  of  tissue  at  once 
separates  and  combines  them,  and,  by  division  of  this  layer,  such  a 
tumor  may  be  cleanly  and  alone  removed  from  the  surrounding  parts ; 
it  may  be  enucleated  or  shelled  out  from  them.  Thus,  with  a  common 
fatty  tumor,  or  a  fibrous  tumor  of  the  uterus,  if  we  cut  along  one  part 
of  its  surface,  we  may,  with  a  blunt  instrument,  detach  the  whole  mass, 
by  splitting  the  layer  of  connective  tissue  which,  like  a  capsule,  in- 
closes and  isolates  it. 

These  are  what  we  commonly  accept  as  the  proper  or  typical  tumors, 
these  which  are  "discontinuous  hypertrophies." 

Other  growths  resemble  these  in  every  character,  except  in  that  they 
are  connected  with  the  adjacent  parts  by  continuity  of  similar  tissue, 
and  thus  appear  as  growths,  not  in,  but  of,  the  parts.  Thus  we  cannot 
exactly  isolate  a  polypus  of  the  nose  or  of  the  uterus:  the  overgrown 
part  cannot  be  enucleated,  because  the  proper  tissue  of  the  nasal  mu- 
cous membrane,  or  of  the  uterine  wall,  is  continued  into  it ;  the  tissue 
of  the  growth  is  here  not  only  uniform,  but  continuous,  with  that  of  the 
adjacent  parts.  So,  too,  with  epulis :  the  gum  itself,  or  the  periosteum 
of  the  jaw  together  with  the  gum,  seems,  by  its  own  excessive  growth, 
to  form  the  tumor :  and  in  other  fibrous  tumors  on  bones,  the  fibres  of 
the  periosteum  appear  to  be  in  the  growth,  and  to  form  part  of  it. 

Such  growths  as  these  might  be  named  "continuous  hypertrophies," 
or  "outgrowths;"  and  I  will,  in  general,  observe  this  distinction  wher- 
ever the  same  tissue  is,  in  diiferent  cases,  found  in  both  forms  of  growth ; 
calling  the  discontinuous  masses,  tumors,  and  the  continuous  ones,  out- 
growths. Thus,  answering  to  the  common  fatty  tumor,  we  find  the  pen- 
dulous and  continuous  fatty  outgrowths  of  the  neck  or  the  abdominal 
walls ;  answering  to  the  fibro-cellular  tumor  that  grows,  as  a  discon- 
tinuous mass,  in  the  scrotum  or  beneath  the  labia,  we  have  the  cuta- 
neous outgrowths  or  enlargements  of  these  parts  ;  to  the  fibrous  tumors 
of  the  uterus  answer  the  fibrous  polypi  or  continuous  outgrowths  of  its 
substance.  All  these  instances  of  clear  distinction  might  lead  us  to 
think  that  a  strong  definition-line  might  be  drawn  to  divide  the  whole 
class  of  innocent  overgrowths  into  tumors  and  outgrowths.  But  when 
we  come  to  the  tumors  of  bone  and  periosteum,  and  to  the  erectile 
tumors,  we  find  the  distinctions  vanishing,  and  in  many  instances  no 
longer  possible. 

It  may  seem  as  if  these  "outgrowths"  needed  distinction  from  the 
"infiltrations"  which  were  spoken  of  as  peculiar  to  malignant  diseases. 
The  distinctions  between  them  are  well  marked.  In  the  outgrowth  the 
new  material  is  like  that  with  which  it  is  connected,  or  like  its  normal 


AND     MALIGNANT    TUMORS.  351 

rudiment,  so  that  it  is  as  if  the  tissue  were  itself  outgrown  ;  but,  in  the 
infiltration,  the  noAv  material  is  dissimilar  from  that  in  the  interstices 
of  which  it  is  placed.  And  in  the  outgrowth  the  materials  of  the  ori- 
ginal part  appear  to  be  at  least  maintained,  if  thej  are  not  increased  ; 
but  in  the  infiltration  thej  degenerate  and  waste.  We  may  compare, 
for  this  contrast,  the  cancerous  diseases  of  the  skin,  with  the  cutaneous 
outgrowths  of  the  labia,  nymphse,  prepuce,  or  scrotum. 

In  thus  briefly  indicating  that  which  appears  still  the  most  reasonable 
method  of  classifying  tumors,  I  have  referred  to  difficulties  which  have 
appeared  to  some  to  be  insuperable  objections  to  any  attempt  at  an 
arrangement  of  these  diseases.  I  will  therefore  state,  so  far  as  I  can, 
what  is  the  real  weight  of  these  objections.* 

First,  it  is  said,  such  classifications  cannot  be  well  made,  because, 
between  each  two  assumed  kinds  or  groups  of  tumors,  intermediate  ex- 
amples may  be  found  transitional,  as  it  were,  from  one  species  to  the 
other:  the  one,  it  is  said,  "runs  into"  the  other;  or,  as  Mr.  Abernethy 
expressed  it,  "diseases  resemble  colors  in  this  respect, — that  a  few  of 
the  primary  ones  only  can  be  discriminated  and  expressed,  whilst  the 
intermediate  shades,  though  distinguishable  by  close  attention  and  com- 
parative observation,  do  not  admit  of  description  and  denomination."f 

This  is  exactly  true  ;  but  Mr.  Abernethy  seems  to  have  felt  that  his 
sentence  supplied  the  answer  to  the  objection  against  classification  by 
structure,  which  it  expressed  ;  for  as  he  did  not,  because  of  the  inter- 
mediate tints,  refuse  to  name  and  arrange  the  primary  colors,  so  neither 
did  he,  nor  need  we,  hesitate  to  name  and  classify  diseases,  and  among 
them  the  principal  forms  of  tumors. 

Moreover,  the  objection  that  structures  may  be  found  intermediate 
between  those  belonging  to  the  chief  forms  of  tumors,  may  be  as  well 
made  against  the  use  of  names  and  systems  for  the  natural  tissues. 
There  are  no  strongly  outlined  characters  defining  any  of  the  natural 
tissues  that  are  ever  imitated  in  tumors ;  intermediate  and  confusing 
forms  are  found  everywhere.  The  various  forms  of  fibro-cartilage,  for 
instance,  fill  up  every  possible  gradation  from  cartilage  to  fibrous  tissue  : 
between  the  looser  and  denser  forms  of  connective  tissue,  between  ten- 
dons, aponeuroses,  and  fasciae,  between  epithelium  and  simple  mem- 
brane, there  are, 'in  the  natural  tissues,  the  narrowest  gradations.  Yet 
we  name  and  arrange  the  natural  tissues  with  some  truth  and  much 
utility ;   and  so  we  may  the  tumors  that  resemble  them. 

Another  objection  against  this  classification  of  tumors  is  made  on 
the  ground  that  there  are  some  in  which  two  or  more  different  tissues 
are  mingled.     Thus,  tumors  may  be  often  found,  in  which  fat  and  fibro- 

*  The  best  statement  of  these  objections  is  by  Vogel ;  but  he  has  well  answered  his  own 
arguments  by  disregarding  them  in  his  nomenclature  of  tumors. 

t  An  attempt  to  form  a  Classification  of  Tumors  according  to  their  Anatomical  Structure. 
Surgical  Works,  vol.  ii,  ed.  1815. 


352  INNOCENT    AND    MALIGNANT    TUMORS. 

cellular  tissue,  or  fibrous  tissue  and  organic  muscle,  or  cartilage  and 
glandular  tissue,  or  other  combinations  meet  together.  But,  among 
these,  some  are  imitations  of  natural  combinations  of  tissues,  as  the 
fibrous  and  organic  muscular  tissues  of  the  uterus  are  imitated  by  the 
so-called  fibrous  tumors  in  its  walls ;  and  of  the  others,  it  need  only  be 
remembered  that  such  combinations  do  occur,  and  these  may  be  put 
aside  from  any  interference  with  arrangement,  by  making  a  series  of 
mixed  tumors,  or  by  adding  to  the  description  of  each  species  the  com- 
binations into  which  it  may  enter. 

Yet  another  objection  is  made,  that  the  characters  of  tumors  are  not 
constant,  and  that  many  must  be  reckoned  as  examples  of  one  species, 
which  are  not  much,  if  at  all,  like  one  another. 

This  diversity  of  characters  is,  indeed,  the  great  difficulty  with  which 
the  pathology  of  tumors  has  to  contend ;  but  the  diversity  is  not  to  be 
called  inconstancy :  it  is  due  to  the  fact  that  each  tumor  has,  like  each 
natural  tissue,  its  phases  of  development,  of  degeneration,  and  of  disease. 
Now,  we  have  scarcely  yet  begun  the  study  of  the  variations  to  which, 
in  each  of  these  phases,  the  several  tumors  are  liable.  We  may  have 
learned,  for  example,  the  general  characters  of  cartilaginous  tumors,  as 
they  grow  in  the  most  favorable  conditions ;  but  how  little  do  we  know 
of  the  various  aspects  these  may  present  when  they  fail  of  due  develop- 
ment, or  fall  in  various  diseases,  or  variously  degenerate !  .  Yet  all 
these  changes  have  to  be  studied  in  the  history  of  every  tumor ;  and  it 
would  be  as  reasonable  to  charge  any  natural  tissue  with  inconstancy, 
because  it  is  altered  in  development  and  disease,  as  to  hold  that  the 
similar  diversity  of  tumors  is  an  objection  to  their  classification  accord- 
ing to  their  structure. 

HoAvever,  while  I  put  this  aside  as  an  objection  against  classification, 
let  me  not  be  thought  to  underrate  it  as  a  difiiculty ;  it  is  the  great 
difiiculty  with  which  we  have  to  contend.  The  work  we  have  to  do  is 
not  only  to  distinguish  each  kind  of  tumor  from  all  other  kinds,  but, 
and  in  order  to  this  end,  to  distinguish,  as  I  may  say,  each  kind  from 
itself,  by  learning  in  each  all  the  changes  occurring  in  the  various 
stages  of  its  life.  The  difiiculty  of  such  a  task  cannot  be  exaggerated, 
while  we  consider  the  rarity  of  the  objects  to  be  studied  ;  but  it  must  be 
overcome  before  we  can  cease  to  speak  of  "anomalous  tumors,"  and  of 
"strange  distempered  masses,"  or,  which  is  more  important,  before  we 
can,  even  after  the  removal  of  a  tumor,  speak  with  certainty  of  the  issue 
of  a  case. 


SIMPLE    CYSTS.  353 


LECTURE   XXII. 

SIMPLE    OR    BARREN    CYSTS. 

The  Cysts,  or  Cystic  Tumors,  to  which  I  shall  devote  this  lecture  and 
the  next,  form  a  very  numerous  group,  and  have  only  or  barely  these 
characters  in  common ;  namely,  that  each  of  them  is  essentially  a  cyst, 
sac,  or  bag,  filled  with  some  substance  which  may  be  regarded  as  en- 
tirely, or  for  the  most  part,  its  product,  whether  as  a  secretion,  or  as 
an  endogenous  growth. 

We  may  conveniently  arrange  cysts  under  the  titles  "  simple"  or 
"barren,"  and  "compound"  or  "proliferous;"  the  former  containing 
fluid  or  unorganized  matter,  the  latter  containing  variously  organized 
bodies. 

Among  the  simple  or  barren  cysts,  we  find  some  that  contain  a  fluid 
like  that  of  one  of  the  serous  membranes ;  such  are  certain  mammary 
cysts,  and  those  of  the  choroid  plexus :  some  are  full  of  synovia-like 
fluid,  as  the  enlarged  bursas :  others  are  full  of  blood,  or  of  colloid,  or 
some  peculiar  abnormal  fluid :  while  others,  forming  the  transition  be- 
tween the  barren  and  the  proliferous  cysts,  contain  more  highly  organic 
secretions,  such  as  milk,  or  mucus,  or  salivary  or  seminal  fluid.  These 
several  forms  we  may  arrange  with  names  appropriate  to  their  contents ; 
as  serous,  synovial,  mucous,  sanguineous,  colloid,  salivary,  seminal,  and 
others. 

Among  the  cysts,  whether  barren  or  proliferous,  it  is  probable  that 
at  least  three  modes  of  origin  may  obtain.  1st.  Some  are  formed  by 
the  enlargement  and  fusion  of  the  spaces  or  areolse  in  connective  or 
other  tissues.  In  these  spaces  fluids  collect  and  accumulate ;  the  tissue 
becomes  rarefied ;  and,  gradually,  the  boundaries  of  the  spaces  are 
levelled  down  and  walled  in,  till  a  perfect  sac  or  cyst  is  formed,  the 
walls  of  which  continue  to  secrete.  Thus  are  produced  the  bursse  over 
the  patellge,  and  others ;  and  to  this  we  may  refer,  at  least  in  some 
cases,  the  formation  of  cysts  in  tumors,  and,  perhaps,  in  other  parts. 

2dly.  Some  cysts  are  formed  by  dilatation  and  growth  of  natural 
ducts  or  sacculi ;  as  are  those  sebaceous  or  epidermal  cysts  which,  formed 
by  enlarged  hair-follicles,  have  permanent  openings.  Such,  also,  are 
certain  cysts  containing  milk,  that  are  formed  of  enlarged  portions  of 
lactiferous  tubes ;  such  the  ovarian  cysts  formed  by  distended  and  over- 
grown Graafian  vesicles  ;  and  such  appear  to  be  certain  cysts  formed  of 
dilated  portions  of  bloodvessels  shut  off  from  the  main  streams. 

3dly.  Many,  and  perhaps  the  great  majority  of  cysts,  such  as  those 
of  the  kidney,  the  choroid  plexuses,  the  chorion,  and  the  thyroid  gland, 
are  formed  by  the  enormous  growth  of  new-formed  elementary  struc- 
tures having  the  characters  of  cells  or  nuclei,  which  pursue  a  morbid 


354  GENERAL    HISTORY    OF    CYSTS. 

course  from  their  origin,  or  from  a  very  early  period  of  their  develop- 
ment. 

It  might,  on  some  grounds,  be  desirable  to  classify  the  cysts  accord- 
ing to  their  respective  modes  of  formation;  separating  the  "secondary 
cysts,"  as  those  have  been  called  Avhich  are  derived  by  growth  or  expan- 
sion of  normal  parts,  from  the  "  primary,"  or,  as  they  might  be  called, 
the  "autogenous"  cysts.  But  at  present,  I  believe,  such  a  division 
cannot  be  made ;  for  of  some  cysts  it  is  impossible  to  say  in  which  me- 
thod they  originate,  and,  in  some  instances,  either  method  may  lead  to 
/an  apparently  similar  result.  Thus,  some  sebaceous  or  epidermal  cysts 
are  clearly  formed  of  overgrown  hair-follicles ;  others  are  of  distinct 
autogenous  origin.  Some  ranulse  are  probably  formed  by  dilatation  of 
the  submaxillary  duct,  obstructed  by  calculi  or  otherwise;  others  by 
anormal  development  of  distinct  cysts,  or  possibly  of  a  bursa  between 
the  muscles  of  the  tongue.*  Some  cysts  in  the  mammary  gland  are 
certainly  dilated  portions  of  ducts ;  others  are,  from  their  origin,  anor- 
mal transformations  of  the  elementary  structures  of  the  gland.  But 
in  each  of  these  cases  it  may  be  impossible,  when  the  cyst  is  fully 
formed,  to  decide  what  was  its  mode  of  origin :  whether  by  growth  of 
parts  once  normally  formed,  or  by  transformation  of  elementary  and 
rudimental  structures. 

Of  the  three  modes  of  the  formation  of  cysts  to  which  I  have  referred, 
the  first  two,  namely,  that  which  is  accomplished  by  expansion  of  areolar 
spaces,  and  that  by  dilatation  and  growth  of  ducts  or  vesicles,  scarcely 
need  an  explanation. 

Indeed,  if  it  were  not  for  some  convenience  in  surgical  practice,  we 
should  not  retain  most  of  the  cysts  thus  formed,  in  the  list  of  tumors ; 
for  their  growth  appears,  in  most  instances,  to  be  due  only  to  the  accu- 
mulation of  the  contents  of  the  obstructed  tube  or  sacculus,  and  to  be 
exactly  adjusted  to  this  accumulation,  and  commensurate  with  it.  Thus 
it  is  in  the  cases  of  ranula  with  obstruction  of  the  submaxillary  duct, 
and  the  similar  dilatations  of  the  pancreatic  duct  ;f  in  the  cystiform 
dilatation  of  the  obstructed  Fallopian  tube;  in  the  dilated  hair-follicles  ; 
in  bursge ;  and  in  some  others.  These  are  all  conventionally  reckoned 
among  cysts  and  arranged  with  tumors :  but  several  of  the  like  kind 
are  never  so  reckoned ;  such  as  the  cyst-like  gall-bladder,  dilated  with 

*  See  Fleischman,  in  Schmidt's  Jahrbucher,  1841,  B.  32,  and  Frerichs,  Ueber  Gallert-oder 
Colloidgeschwulste,  Gottingen,  1847,  p.  37. 

f  An  excellent  illustration  of  cystiform  dilatation  of  the  pancreas,  through  obstruction  of 
the  duct,  came  under  the  notice  of  the  editor  a  short  time  back,  in  the  body  of  a  man  who 
died  with  a  cancerous  growth  in  the  head  of  the  gland.  The  pancreas  at  first  sight  ap- 
peared to  have  been  converted  into  a  large  multilocular  cyst;  but  a  careful  examination 
convinced  him  that  the  cyst-like  dilatations  were  nothing  more  than  the  expanded  acini, 
filled  with  the  somewhat  thickened  and  concentrated  secretion  of  the  gland.  These  dila- 
tations all  commimicated  with  each  other  through  the  duct,  so  that  when  a  puncture  was 
made  into  one,  and  a  pipette  introduced,  all  the  fluid  was  drawn  off.  An  analysis  of  this 
fluid  may  be  found  recorded  in  Brown-S^quard's  Jal.  de  la  Phys.     April,  1861. 


GENERAL    HISTORY    OF    CYSTS.  355 

thin  mucus,  -when  the  cystic  duct  is  completely  obstructed ;  the  dila- 
tation of  the  uterus,  filled  with  serum  after  closure  of  its  external 
orifice;  the  distended  sheath  of  a  tendon;  and  others.  Convenience 
and  common  usage  have  decided  what  cysts  may  be  grouped  with  those 
which  alone,  we  may  anticipate,  will  be  classed  with  tumors  when  patho- 
logy becomes  more  accurate  and  strict.  Convenience  alone,  also,  decides 
for  the  omission,  from  so  vague  a  class  as  this,  of  the  sacs  or  capsules 
that  are  formed  round  foreign  bodies  and  solid  tumors,  and  of  the  sacs 
that  may  be  formed  on  the  free  surfaces  of  extravasated  blood  or  in- 
flammatory exudation. 

For  the  third  method  of  formation  enumerated  above,  a  more  de- 
tailed account  is  required  ;  and  this  I  will  now  endeavor  to  give. 

The  general  structures  of  the  cysts  thus  formed  may  be  best  studied 
in  those  that  are  so  commonly  found  in  the  kidneys,  or  the  mammary 
or  thyroid  gland,  or  in  any  instance  of  an  ordinary  serous  cyst.  Such 
a  cyst,  when  large  enough  for  naked-eye  examination,  is  usually  con- 
structed of  fine,  well-formed,  connective  tissue,  of  which  the  filaments 
are  commonly  mingled  with  nuclei,  or  nucleus  fibres,  and  are  variously 
interwoven  in  a  single  layer,  or  in  many  that  are  separable.  The  mem- 
branous walls  thus  formed  are,  in  general,  rather  firmly  connected  with 
the  adjacent  parts,  so  that  the  cysts  cannot  easily  be  removed  entire ; 
and  from  these  parts  they  derive  the  bloodvessels  that  usually  ramify 
copiously  upon  them.  They  are  usually,  also,  lined  with  epithelium, 
which  is  generally  of  the  tessellated  form,  and  may  consist,  according 
to  Rokitansky,  of  either  nuclei  or  nucleated  cells.* 

I  am  not  aware  that  minute  examinations  have  been  made  of  the 
modes  of  earliest  formation  of  any  of  the  cysts  of  this  kind,  that  are 
common  subjects  of  surgical  consideration  ;  but  there  can  be  little  doubt 
that,  in  their  formation,  they  resemble  the  cysts  of  the  kidney  and 
other  internal  organs.  In  these  organs  the  origin  and  progress  of  cysts 
have  been  profoundly  studied  by  Rokitansky  ;f  and  I  shall  best  describe 
them  by  giving  an  abstract  of  some  of  his  observations,  in  illustration 
of  a  copy  of  one  of  his  outline  sketches  of  the  minute  structure  of  the 
cystic  disease  of  the  kidney  (Fig.  44).     They  confirm  and  greatly  ex- 

*  Rokitansky  says  (Ueber  die  Cyste,  p.  4)  there  is  often  no  epithelium  in  the  larger  cysts, 
and  their  "inner  layer  is  a  nucleated  structureless  or  striated  blastema,  externally  splitting 
into  fibres  in  the  direction  of  the  long  axis  of  the  oval  nuclei  it  contains."  Epithelial  cells, 
apparently  altered  so  as  to  resemble  very  large  cells  of  inflammatory  lymph,  are  commonly 
found  in  the  tenacious  contents  of  btirsse.  M.  Giraldes  tells  me  that  the  cysts  which  so  often 
occur  in  the  antrum  are  commonly  lined  vvith  ciliary  epithelium.  In  other  localities,  also, 
cysts  have  been  observed,  which  possessed  a  more  or  less  perfect  lining  of  ciliated  epithe- 
lium. Thus  Friedrich  (Virchow's  Archiv,  vol.  xi,  p.  466)  describes  such  a  cyst  in  the  liver  : 
Virchow  (same  vol..  p.  469)  refers  to  a  case  by  Luschka,  where,  in  the  interior  of  an  ovarian 
cyst,  papillary  excrescences,  covered  by  ciliated  epithelium-cells,  were  found  ;  and  Athol 
Johnson  (Med.  Times  and  Gaz.,  Feb.  16,  1856)  relates  a  case  of  fibro-cystic  disease  of  the 
testicle,  some  of  the  cysts  in  which  had  a  ciliated  epithelial  lining. 

t  Ueber  die  Cyste.     Wien,  1850. 


356 


GENERAL    HISTORY    OF    CYSTS. 


tend  the  results  obtained  by  the  similar  investigations  of  Frerichs,*  and 
they  fully  establish  the  accuracy  of  the  observations  on  the  cystic  de- 
generation   of     the 
I'ig.  44.  kidney,  which  were 

made  by  Mr.  Sim- 
on, f  to  whom  patho- 
logy is  indebted  for 
the  first  sure  step  in 
this  rich  path  of  in- 
quiry. They  may  be 
repeated  in  almost 
any  portion  of  a  gra- 
nular kidney  con- 
taining cysts,  or  in  a 
choroid  plexus  with 
cysts:  but,  I  believe, 
the  process  may  be 
best  traced  in  the 
cystic  disease  of  the 
embryonic  chorion, 
the  hydatid  mole,  as 
it  has  been  called.|     To  this  I  shall  again  refer  in  the  next  lecture. 

In  a  portion  of  a  granular  and  cystic  kidney,  nests,  as  E,okitansky 
calls  them,  of  delicate  vesicles,  from  a  size  just  visible  to  that  of  a  millet 
seed,  may  be  seen  imbedded  in  a  reddish-gray  or  whitish  substance. 
These  differ  in  size  alone  from  the  larger  cysts  to  which  one's  attention 
would  be  sooner  attracted ;  and,  on  the  other  side,  it  is  only  in  size  that 
they  differ  from  many  much  smaller.  For  if  a  portion  of  such  a  nest  be 
examined  with  the  microscope,  one  finds,  together  with  the  debris  of 
th^  kidney,  variously  diseased  it  may  be,  a  vast  number  of  vesicles  or 
cysts  that  were  invisible  to  the  naked  eye. 

The  most  striking  of  these  have  a  wall  consisting  of  layers  of  fibres 
scattered  over  with  curved  nuclei  (a),  and  are  filled  with  granulated 
nuclei,  or,  more  rarely,  with  round  or  polyhedral  cells,  some  of  which 
may  contain  a  molecular  or  granular  pigmental  matter  (d).  In  many 
of  these  cysts,  the  nuclei  or  cells  are  reduced  to  an  epithelial  lining  of 
the  cyst;  and  in  some  even  this  is  absent,  and  the  "barren"  cyst  is 
filled  with  a  clear  or  opaline  adhesive  fluid. 

From  the  size  just  visible  to  the  naked  eye,  such  cysts  vary  to  ^^gth 
of  an  inch  in  diameter  ;  and,  together  with  these,  are  cysts  whose  walls 
(though  their  contents  are  like  those  of  the  others)  consist  of  a  struc- 
tureless hyaline  membrane  :  and  these  lie  in  a  stroma  which  is  equally 

*  Ueber  Gallert-oder  Colloidgeschwiilste. 

t  On  Subacute  Inflammation  of  the  Kidney,  in  the  Medico-Chirurgical  Transactions,  vol. 
XXX.     See  also  Dr.  Gairdner  on  Cyst  Formations  in  Kidney,  Edin.  Med.  Jal.,  1S53. 
J  Mettenheimer,  in  Miiller's  Archiv,  1850. 


GENERAL    HISTORY    OF    CYSTS.  357 

simple,  but  seems  to  develop  itself  gradually  into  a  fibrous  structure 
circumscribing  the  cysts. 

Moreover,  one  finds,  in  the  same  specimens  (as  in  the  lower  part  of 
Fig.  44),  structures  of  the  most  varied  sizes,  which,  except  in  size,  agree 
completely  with  the  last-mentioned  simple  and  structureless  vesicles, 
and  show  every  grade  of  size  down  to  that  which  is  just  larger  than  a 
nucleus.  The  smallest  of  these  contain  a  clear  fluid,  or  are  slightly 
granulated  :  in  the  larger  there  is  a  central  nucleus,  and  to  this  are 
added  a  second,  a  third,  and  a  fourth  nucleus,  and  so  on  till  there 
appear  several,  which  fill  up  the  commensurately  enlarged  vesicle 
(g,  g,  e,  &c.).  Now,  in  such  a  nucleus  seems  to  lie  the  nucleus  of  the 
history  of  development  of  those  autogenous  cysts,  not  in  the  kidney 
alone,  but  in  any  part  in  which  they  may  occur,  A  nucleus  grows  to 
be  a  cyst,  whether  a  simple  or  barren  one,  or  one  that  has  an  endoge- 
nous production  of  nuclei,  or  cells,  or  any  other  structures. 

It  would  be  tedious  now  to  trace,  from  this  general  sketch  of  their 
origin,  all  the  phases  through  which  such  cysts  may  pass.  Rokitansky 
has  done  it  amply.  We  have  here  the  elementary  constituents.  But 
the  simple  cyst-wall  is  capable,  not  only  of  growing,  but  of  acquiring, 
the  laminar  and  nucleated  fibrous  tissue  which  we  find  in  its  full  estate  ; 
acquiring  these,  we  may  presume,  just  as  more  normally,  the  simple 
membranous  wall  of  a  new  bloodvessel  acquires,  as  it  grows,  the  nuclei 
and  fibrous  tissue  that  belong  to  its  more  perfect  state.  Such  might  be 
the  least  abnormal  course  of  any  cyst ;  but  from  this  it  may  deviate ; 
thickening,  acquiring  continually  new  layers,  calcifying,  and  in  other 
ways  showing  the  signs  of  degeneration  or  disease.  The  contents, 
also,  of  the  cyst  may  assume  even  yet  more  various  forms :  to  name 
only  the  extremes, — they  may  retain  the  simple  state  of  liquid ;  or  with 
liquid  there  may  be  a  simple,  or  a  specially  secreting,  epithelial  layer ; 
or,  a  series  of  successively  inclosed  nuclei  or  cells  may  be  formed  within 
that  which  first  enlarges ;  or,  the  contents  may  acquire  the  structure  of 
well-organized  glands,  or  of  cancer,  or  some  other  tissue  ;  and  between 
these  extremes,  according  to  conditions  which  we  have  no  power  to  trace 
or  explain,  they  may  pass  in  any  of  the  manifold  ways  of  wrong,  the 
ends  of  which  I  shall  have  to  describe.* 

*  In  the  small  cysts  containing  a  gelatinous-looking  or  honey-like  substance,  which  not 
unfrequently  occur  in  the  ovary,  the  editor  has  more  than  once,  on  making  microscopic  ex- 
amination, found  the  yellow  mass  for  the  most  part  composed  of  pale  nucleated  cells,  some 
of  which  were  little  larger  than  a  human  white  blood  corpuscle,  others  were  several  times 
as  large,  and  others  again  were  intermediate  in  size.  In  these  larger  cells  many  nuclei,  evi- 
dently the  products  of  endogenous  development,  were  seen,  from  which  circumstance  they 
were  more  opaque  than  the  smaller  cells.  Mr.  Goodsir  has  described  and  figured  (Anat.  and 
Path.  Obs.,  p.  107,  pi.  1,  figs.  1,2,  3,  1845)  numerous  nucleated  cells  from  the  honey-like  con- 
tents of  a  cyst  removed  from  beneath  the  tongue.  Inside  many  of  these  cells,  nuclei  in 
various  stages  of  development  were  seen,  and  in  these  cases  the  cells  were  more  opaque, 
and  distended  beyond  the  average  size.  By  the  multiplication  of  the  nuclei  in  the  interior 
of  these  cells  the  reproduction  of  new  cells  was  produced. 


358  GENERAL    HISTORY    OF     CYSTS. 

Important  as  the  history  of  cysts  may  be  in  its  direct  bearings,  yet 
these  are  not  all  that  we  may  observe  in  it.  In  their  history  I  cannot 
but  think  we  may  discern  an  image  of  the  first  form  and  early  progress 
of  many  innocent  solid  tumors  also.  For,  as  the  cyst  is  traced  from 
the  mere  nucleus,  onwards  to  its  extreme  size  or  complexity  of  struc- 
ture or  contents,  so,  it  is  very  probable,  from  the  numerous  correspon- 
dences between  them,  that  these  solid  tumors  also  have  a  similar  begin- 
ning in  some  detached  element,  or  tissue-germ,  or  in  some  group  of 
such  germs,  which,  in  their  development,  multiplication,  and  growth, 
may  coalesce,  and  then  may  appropriate,  or  exclude  for  absorption,  the 
intervening  substance. 

Thus,  in  the  form  of  erring  nuclei,  we  may,  I  think,  almost  appre- 
hend the  structural  origin  of  these  cysts  and  tumors ;  yet,  if  we  may, 
the  question  still  remains  whether  the  elementary  structures  in  which 
they  begin,  be  some  new  and  special  morbid  elements,  or  some  natural 
rudimental  structures  perverted  from  their  normal  course.  Mr.  Simon, 
speaking  of  the  cysts  of  the  kidney,  regards  them  as  "vesicular  trans- 
formations of  the  ultimate  structure  of  the  gland  ;"  and  to  this  view, 
without  adopting  some  ingenious  suppositions  which  he  has  connected 
with  it,  I  would  adhere.  For,  unless  a  cyst  or  a  solid  tumor  (assuming 
this  mode  of  their  origin  to  be  correct)  were  really  a  transformation  of 
a  nucleus,  or  a  cell,  of  the  part  in  which  it  grows,  we  could  not  under- 
stand the  very  general  similarity  that  we  find  between  the  contents  of 
certain  cysts,  and  the  secretions  or  structures  of  the  glands  in  or  near 
which  they  occur ;  nor  yet  the  likeness  which  commonly  exists  between 
the  solid  tumor  and  the  tissue  in  which  it  is  imbedded.  These  things 
are  as  if  the  first  beginning  of  the  abnormal  growth  were  in  some  de- 
tached element  of  the  natural  tissue,  which  element,  being  perverted 
from  its  normal  course,  thenceforward  multiplies  and  grows,  conforming 
with  the  type  in  minute  structure  and  composition,  but  more  and  more 
widely  deviating  from  it  in  shape  and  size.* 

Such  are  the  facts,  and  such  the  speculations  that  we  may  entertain, 
respecting  the  origin,  or,  at  least,  the  smallest  visible  beginning,  of  a 
cyst  or  an  innocent  solid  tumor.  Need  I  add  that  if  even  this  be  true, 
we  are  yet  far  from  the  explanation  of  the  cardinal  point  in  the  patho- 

*  The  doctrine  of  the  continuous  development  of  texture — of  the  descent  of  cells  and  nu- 
clei from  pre-existing  cells  and  nuclei — bears  out  the  opinion  expressed  in  the  text.  It  ex. 
plains  how,  by  an  irregularity  in  the  development  of  the  cells  and  nuclei  of  a  part,  tumors 
may  arise  in  many  of  the  textures  corresponding  in  structure  to  the  tissues  in  which  they 
take  their  origin.  How  fibrous  tumors  spring  from  periosteum  and  other  forms  of  connec- 
tive tissue;  adipose  and  fibro-cellular  tumors  in  the  subcutaneous  or  submucous  areolar  tis- 
sue; cartilaginous,  myeloid,  and  osseous  tumors  in  connection  with  bone  ;  glandular  tumors 
with  glands,  &c.  The  intimate  structural  relations  of  the  adipose  and  connective  tissues,  the 
close  morphological  relations  which  have  of  late  been  shown  to  exist  between  connective 
tissue,  bone  and  cartilage — that  the  connective-tissue-corpuscles,  bone-corpuscles,  and  carti- 
lage-cells, are  strictly  homologous  parts — also  serve  to  explain  the  occasional  origin  in  the 
connective  tissue  of  fatty  tumors,  and  of  growths,  in  the  formation  of  which,  bone  and  carti- 
lage take  an  important  share. 


GASEOUS    AND    SEROUS     CYSTS.  359 

logy  of  tumors, — their  continual  growing.  Why  should  these  detached 
tissue-germs,  or  any  less  minute  and  less  isolated  portion  of  an  organ, 
grow,  while  all  other  germs  and  parts  that  are  most  like  them  remain 
unchanged  ?     I  have  already  confessed  my  ignorance. 

I  will  endeavor  now  to  illustrate  the  histories  of  particular  forms  of 
the  simple  or  harren  cysts. 

1.  The  first  that  may  be  enumerated  are  Gaseous  Cysts.  I  know, 
indeed,  concerning  them  only  the  specimens  placed  by  Hunter  in  his 
Museum;*  but  these  should  be  admired,  or  almost  venerated;  for  their 
histories  include  the  honorable  names  of  Hunter,  of  Jenner,  and  of 
Cavendish.  Mr.  Hunter  says  of  them, — "I  have  apiece  of  the  intes- 
tine of  a  hog,  which  has  a  number  of  air-bladders  in  it."  .  .  .  "  It  was 
sent  to  me  by  my  friend  Mr.  Jenner,  surgeon,  at  Berkley,  who  informed 
me  that  this  appearance  is  found  very  frequently  upon  the  intestines  of 
hogs  that  are  killed  in  the  summer  months."  ..."  Mr.  Cavendish 
was  so  kind  as  to  examine  a  little  of  this  air ;  and  he  found  '  it  con- 
tained a  little  fixed  air,  and  the  remainder  not  at  all  inflammable,  and 
almost  completely  phlogisticated.'  "f 

What  a  relic  have  we  here  !  Surely,  never,  on  an  object  so  mean  to 
common  apprehensions,  did  such  rays  of  intellectual  light  converge,  as  on 
these  to  which  were  addressed  the  frequent  and  inquiring  observations 
of  Jenner,  the  keen  analysis  by  Cavendish,  and  the  vast  comparison  and 
deep  reflection  of  John  Hunter  !  Surely,  never  were  the  elements  of 
an  inductive  process  combined  in  such  perfection  !  Jenner  to  observe  ; 
Cavendish  to  analyze ;   Hunter  to  compare  and  to  reflect. 

2.  The  Serous  Cysts,  or  Hygromata,  are,  of  all  the  order,  the  most 
abundant.  The  term  includes  nearly  all  such  as  have  thinly  liquid,  or 
honey-like  contents,  of  yellow,  brown,  or  other  tint.  Their  most  fre- 
quent seats  are,  by  a  hundred-fold  majority,  in  or  near  the  secreting 
glands  or  membranes,  or  the  so-called  vascular  glands  ;  but  there  is 
scarcely  a  part  in  which  they  may  not  be  found.  Their  frequency  in 
connection  with  secreting  structures  has  led  some  to  hold  that  they  are 
all  examples  of  perverted  epithelial  or  gland-cells  :  but  their  occurrence 
in  such  parts  as  bones  and  nerves,  among  deep-seated  muscles,  and  in 
fibrous  tumors,  makes  it  sure  that  they  may  originate  independently  of 
gland-cells  ;|  though  why  any  element  of  a  solid  tissue  should  retain 

*  Museum  of  the  Coll.  of  Surg.,  No.  153-4. 

■f  See  Hunter's  Works,  vol.  iv,  p.  98,  and  Description  of  PI.  xxxvii. 

J  Some  very  interesting  specimens  of  serous  cysts  in  bones  are  in  the  Museum  of  St. 
George's  Hospital.  They  are  described  by  Mr.  Ccesar  Hawkins,  in  his  Lectures  on  Tumors, 
in  the  Medical  Gazette,  vols,  xxi,  xxii ;  and  in  a  Clinical  Lecture  in  the  same,  vol.  xxv,  p. 
472.  See  also,  a  remarkable  case  by  Vanzetti,  in  Schuh  (Pseudo-plasmen,  175).  There  are 
some  remarkable  specimens  of  cysts  in  the  antrum,  in  the  Museum  of  St.  Thomas's  Hospital, 
prepared  by  Mr.  Wm.  Adams,  who  showed  them  to  me.     M.  Giraldes  considers  all  such  as 


360  SEROUS    CYSTS. 

the  vesicular  form  which  it  has  in  its  germ  state,  and  in  that  form  grow, 
we  cannot  tell. 

Of  this  numerous  group  of  serous  cysts,  however,  I  will  speak  at 
present  of  only  such  as  may  best  illustrate  their  general  pathology, 
and  are  of  the  most  importance  in  surgical  practice ;  and  I  will,  to  these 
ends,  refer  chiefly  to  the  cysts  in  the  neck,  the  mammary  gland,  and 
the  gums. 

Single  serous  cysts  in  the  neck  form  what  have  been  called  "  hydro- 
celes of  the  neck,"  and  are  well  exemplified  by  a  specimen  in  the  Mu- 
seum of  the  College.*  This  is  a  single  oval  cyst,  with  thin,  flaccid, 
membranous  walls,  which  even  now,  after  shrinking,  measures  more 
than  six  inches  in  its  chief  diameter.  It  was  successfully  removed  by 
Mr.  Thomas  Blizard  from  between  the  platysma  and  sterno-mastoid 
muscles  :  and  a  part  of  it  is  said  to  have  passed  behind  the  clavicle.  It 
was  filled  with  a  clear  brownish  fluid. 

Such  cysts,  but  various  in  size  and  other  characters,  are  more  apt  to 
occur  in  the  neck  than  in  any  other  part  of  the  body.  Many  are  single 
cysts  like  this ;  but  others  are  complex,  having  many  cavities,  whether 
separate  or  communicating ;  and  some  consist  of  very  numerous  cysts, 
even  of  hundreds,  clustered  in  one  comparatively  firm  mass. 

In  situation,  too,  they  are  various.  In  some  cases  they  lie  in  the 
front  of  the  neck  ;  in  others,  at  one  or  both  sides :  they  may  lie  by  the 
lower  jaw,  over  the  parotid,  by  the  clavicle,  or  anywhere  or  everywhere 
in  the  mid-spaces.  And  in  any  of  these  situations  they  may  extend 
very  deeply  among  the  structures  of  the  neck,  and  may  adhere  to  them 
so  closely,  and  may  so  thinly  cover  them,  as  scarcely  to  conceal  them 
when  laid  open.  Their  date  of  origin  is  often  obscure.  In  many,  per- 
haps in  the  majority  of  cases,  they  appear  to  be  congenital  ;t  but  they 
may  be  first  observed  at  any  later  period  of  life.     Last  year  Mr.  Law- 

these  to  be  formed  by  cystic  disease  of  the  gland-structures,  discovered  by  him  in  the  mucous 
membrane  of  the  antrum.  His  description  of  the  normal  anatomy  of  the  mucous  membrane 
of  the  antrum,  and  of  the  mode  of  formation  of  the  cysts  in  that  locality,  is  in  the  Memoires 
de  la  Societe  de  Chirurgerie  de  Paris,  1853,  and  in  a  separate  essay,  "  Recherches  sur  les 
Kystes  Muqueux  des  sinus  Maxillaire,"  Paris,  1860. 

*  Mus.  Coll.  Surg.  146.  Many  well-marked  examples  of  the  disease  in  all  its  forms 
are  recorded  by  Dr.  O'Beirne  (Dublin  Jour,  of  Med.  and  Chem.  Sc.  vol.  vi,  p.  834)  ;  Mr. 
Lawrence  (Med.-Chir.  Trans,  vol.  xvii,  p.  44) ;  Mr.  Csesar  Hawkins  (Med.-Chir.  Trans,  vol. 
xxii,  p.  231)  ;  Mr.  Liston  (Practical  Surgery,  p.  330,  ed.  1846)  ;  and  others.  A  monograph 
by  Wernher  (Die  angeborenen  Cysten-Hygrome,  Giessen,  1843)  is  referred  to  by  Bruch,  1. 
c,  but  I  have  not  been  able  to  see  it. 

■j"  The  essay  by  Wernher,  referred  to  in  the  foot-note  above,  probably  includes  all  the 
cases  of  congenital  serous  cysts  in  the  neck  at  that  time  recorded  (1843).  Since  then, 
Gilles  (De  Hygromatis  Cysticis  Congenitis,  Bonnse,  1852)  has  added  three.  But  these  were 
complex  tumors,  formed  of  cysts,  adipose  and  fibrous  tissues,  bone,  and  one  even  contained 
a  tooth.  These  growths,  therefore,  must  be  distinguished  from  simple  cysts.  They  are, 
probably,  of  the  nature  of  monstrosities  by  excess,  and  are  allied  to  those  congenital  cysts 
which  are  occasionally  found  connected  with  the  sacrum  and  coccyx,  and  of  which  a  very 
interesting  account,  by  Prof  Simpson,  may  be  found  in  the  Med.  Times  and  Gazette,  July 
2,  1859.     Also  by  Dr.  Glaser  in  Virchow's  Archiv,  1858,  p.  187. 


SEEOUS    CYSTS.  361 

rence  removed  a  collection  of  four  large  cysts  from  over  the  parotid 
gland  and  mastoid  region  of  a  man,  twenty-eight  years  old,  who  had 
observed  their  beginning  only  seven  years  previously.  Three  of  these 
were  filled  with  serum,  and  one  with  pus. 

Of  course,  in  such  a  variety  of  forms,  there  must  be  more  than  one 
kind,  in  the  group  of  cysts  that  are  thus,  for  mere  convenience,  placed 
together.  The  variety  of  origins,  indeed,  to  which  cysts  in  the  neck 
may  be  traced,  gives  them  peculiar  interest  in  relation  to  the  general 
pathology  of  cysts. 

Some  are  evidently  connected  with  the  thyroid  gland;  though,  being 
singly  developed,  and  growing  to  a  very  large  size,  their  relation  to  it 
may  be  at  length  obscured,  and  they  may  appear,  during  life,  quite 
isolated.  A  woman,  forty-eight  years  old,  was  under  Mr.  Vincent's 
care,  in  St.  Bartholomew's  Hospital,  in  July,  1841,  with  a  tumor  in  the 
front  of  her  neck  as  large  as  the  head  of  a  child  two  years  old.  The 
tumor  contained  fluid,  which  was  twice  withdrawn  with  a  trocar.  At 
the  first  time  the  fluid  looked  like  serum,  but  coagulated  spontaneously  ; 
at  the  second,  it  was  mixed  with  blood.  After  the  second  operation 
the  cyst  inflamed  and  discharged  grumous  and  sanious  pus  ;  but  it  also 
enlarged  quickly,  and  the  patient  died  unexpectedly,  and  rather  sud- 
denly, suff"ocated. 

The  preparation*  displays  a  cyst  occupying  nearly  the  whole  right 
lobe  of  the  thyroid  gland  :  its  walls  are  nearly  two  lines  in  thickness  ; 
its  cavity  was  full  of  lymph,  pus,  and  blood  ;  and  the  sudden  death  was 
due  to  a  discharge  of  a  great  part  of  its  contents  into  the  pharynx  and 
larynx,  through  an  ulcerated  aperture  into  the  former. 

Besides  these  cysts  which  lie  within  the  thyroid  gland,  some  that  lie 
near  to  it  are  very  probably  of  the  same  nature ;  cysts  formed  in  some 
outlying  portion  of  the  gland,  such  as  I  referred  to  in  the  last  lecture. 
But  of  this  mode  of  origin  we  can  scarcely  have  a  proof  when  the  cyst 
is  fully  formed  and  largely  grown. 

Other  of  these  cysts  in  the  neck  appear  to  be  transformations  of  vas- 
cular tumors  ;  i.  e.  of  erectile  vascular  growths  or  nsevi.  I  shall  refer 
to  this  point  again  :  it  is  made  probable  by  the  close  connection  which 
some  of  these  cysts  have  with  large  deep-seated  veins ;  by  the  occa- 
sional opening  of  bloodvessels  into  their  cavities ;  and  by  their  some- 
times distinctly  forming  portions  of  vascular  nsevi.  A  girl,  three  aiid 
a  half  years  old,  was  under  Mr.  Lawrence's  care,  in  1849,  in  St.  Bar- 
tholomew's Hospital,  with  a  large  soft  and  obscurely  fluctuating  tumor 
covering  the  greater  part  of  the  left  side  of  the  neck,  and  the  lower 
part  of  the  cheek.  Such  a  swelling  had  existed  from  birth,  but  it  had 
of  late  enlarged  very  much.  It  was  composed  of  a  cluster  of  close-set 
cysts,  containing  spontaneously  coagulable  fluid ;  but  at  its  upper  part 
a  firmer  portion  of  its  mass  consisted  of  a  collection   of  tortuous  and 

*  Museum  of  St.  Bartholomew's  Hospital,  Ser.  xxii,  No.  16. 
24 


362  SEROUS    CYSTS. 

dilated  "bloodvessels  like  those  of  a  nsevus.  The  examination  made  of 
it,  by  Mr.  Coote,*  after  its  removal,  was  such  as  to  leave  little  doubt 
in  his  mind  that  it  had  origin  in  or  with  a  nsevous  growth :  and  other 
cases,  to  which  I  shall  refer  in  speaking  of  erectile  tumors,  have  con- 
firmed this  view,  especially  some  of  those  which  are  published  by  Mr. 
Hawkins. 

But  when  we  have  separated  all  the  serous  cysts  in  the  neck  that 
may  be  referred  to  these  two  sources,  there  will  probably  still  remain 
many  that  we  can  assign  to  no  such  mode  of  origin,  and  which  at 
present  we  must  class  among  primary  or  autogenous  cysts,  independent 
of  any  secreting  structure. 

Among  these  are  some  with  fluid  contents  of  peculiar  viscidity,  ropy, 
or  honey-like,  and  deriving  a  peculiar  aspect  from  including  abundant 
crystals  of  cholesterine.  Such  contents  may  occur,  perhaps,  in  any 
cyst  in  the  neck  or  elsewhere ;  but  they  appear  to  be  comparatively 
frequent  at  or  near  the  front  of  the  larynx.  In  the  College  Museum 
there  is  such  a  cyst,t  attached  to  the  hyoid  bone  of  a  sailor,  who  was 
between  fifty  and  sixty  years  old,  and  in  whom  it  had  existed  nearly 
as  long  as  he  could  remember.  It  contained  a  brownish-yellow,  grum- 
ous,  honey-like  fluid,  with  abundant  crystals  of  cholesterine. 

In  1849,  Mr.  Lawrence  had,  at  St.  Bartholomew's  Hospital,  a 
patient,  thirty-five  years  old,  on  the  left  side  of  whose  neck,  directly 
over  and  closely  attached  to  the  thyro-hyoid  membrane,  was  a  smooth 
oval  tumor,  about  an  inch  in  length.  He  had  observed  a  regular  in- 
crease of  this  tumor  for  five  or  six  years;  but  its  bulk  and  deformity 
alone  were  inconvenient.  Mr.  Lawrence  freely  cut  into  it,  and  let  out 
a  thick  honey-like  fluid,  in  which  large  groups  of  crystals  of  choleste- 
rine were  visible  even  with  the  naked  eye.  The  cyst,  after  the  incision, 
suppurated,  and  then  the  wound  healed,  and  the  patient  left  the  hospital 
quite  well :  but  I  have  lately  seen  him  w^ith  an  appearance  as  if  some 
remains  of  the  cyst  were  again  filling. 

Cysts  like  the  last-described  are  not  uncommon  in  or  near  the  gums, 
lying  usually  behind  the  reflection  of  the  mucous  membrane  from  the 
gum  to  the  cheek.  Their  occasional  large  size,  and  their  thick  tough 
walls  obscuring  the  sense  of  fluctuation,  may  make  them  at  first  look 
formidable.  A  woman,  thirty-eight  years  old,  was  under  my  care  in 
1849,  in  whom,  at  first  sight,  I  could  not  but  suppose  something  was 
distending  the  antrum,  so  closely  was  the  deformity  of  the  face  due  to 
such  diseases  imitated.  But  the  swelling  was  soft  and  elastic,  and  pro- 
jected the  thin  mucous  membrane  of  the  gum  of  the  upper  jaw,  like  a 
half-empty  sac.     I  cut  into  the  sac,  and  let  out  nearly  an  ounce  of 

""  Lecture  by  Mr.  Lawrence,  in  the  Medical  Times,  November  30,  1850. 

f  Mus.  Coll.  Surg.,  148.  These,  I  presume,  are  examples  of  Meliceris.  The  cysts 
which  Mailer  describes  under  the  name  of  cholesteatoma  are  quite  different  from  these,  and 
will  be  noticed  with  tlie  cutaneous  cysts  in  the  next  lecture. 


SEROUS    CYSTS.  363 

turbid  brownish  fluid,  sparkling  with  crystals  of  cholesterine.  The 
posterior  wall  of  the  cyst  rested  in  a  deep  excavation  on  the  surface  of 
the  alveolar  border  of  the  upper  jaw ;  an  adaptation  of  shape  attained, 
I  suppose,  as  the  result  of  the  long-continued  pressure  of  the  cyst, 
which  had  existed  six  years. 

At  nearly  the  same  time  a  young  man  was  under  my  care  with  a 
similar  swelling  of  larger  size,  which  he  ascribed  to  an  injury  of  the 
gum  or  alveolar  border  of  the  upper  jaw  only  six  months  previously. 
In  neither  of  the  cases  could  I  find  any  disease  of  the  maxillary  bone ; 
but  it  sometimes  exists  in  intimate  connection  with  these  cysts,  and 
sometimes  the  fang  or  socket  of  the  nearest  tooth  is  diseased.  I  lately 
saw  a  lady  in  whom  a  small  cyst  of  this  kind  had  existed  twenty-seven 
years,  almost  daily  discharging  and  refilling.  It  had  its  origin  in  a 
blow  by  which  the  two  median  upper  incisors  were  loosened.  One  of 
them  was  again  firmly  fixed ;  the  other  had  remained  slightly  loose, 
and  its  crown  was  dark. 

In  no  organ  is  the  formation  of  cysts  more  important  than  in  the 
mammary  gland.  Every  variety  of  them  may  be  found  here  :  but  I 
will  speak  at  present  of  only  the  serous  cysts. 

Some  of  these  cysts  are  dilated  ducts,  or  portions  of  ducts  grown  into 
the  cyst-form.  During  lactation,  cysts  thus  derived  may  be  filled  with 
milk,  and  may  attain  an  enormous  size,  so  as  to  hold,  for  example,  a 
pint  or  more  of  milk.*  In  other  cases  they  may  contain  the  remains 
of  milk,  as  fatty  matter,  epithelial  scales,  &c. ;  or  they  may  be  filled 
with  transparent  watery  fluid,  without  coagulable  matter  ;f  but  much 
more  commonly  they  contain  serous  fluid,  pure,  or  variously  tinged  with 
blood,  or  its  altered  coloring  matter,  or  various  green,  or  brown,  or 
nearly  black  fluids. | 

The  complete  proof  of  the  origin  of  some  of  these  cysts  as  dilated 
portions  of  ducts  is,  that  by  pressure  they  may  be  emptied  through  the 
nipple,  or  that  bristles  may  be  passed  into  them  from  the  orifices  of 
tubes.  But  although  these  facts  may  be  often  observed,  yet  I  agree 
with  Mr.  Birkett  in  thinking  that  the  majority  of  cysts  in  the  mammary 
gland  are  formed  in  the  manner  of  the  renal  cysts,  to  which,  indeed, 
they  present  many  points  of  resemblance. 

The  most  notable  instances  of  mammary  cysts  are  those  in  which 
the  whole  of  the  gland  is  found  beset  with  them.  This  may  occur 
while  the  proper  substance  of  the  gland  appears  quite  healthy ;  §  but  I 

*  See  a  case  by  M.  Jobert  de  Lamballe,  in  the  Med.  Times,  January  4,  11,  1845  ;  and  a 
collection  of  cases  by  Mr.  Birkett,  in  one  of  which  ten  pints  of  milk  were  evacuated  (Dis- 
eases of  the  Breast,  p.  201). 

f  Brodie,  Lectures  on  Pathology  and  Surgery,  p.  155. 

J  Their  various  contents  are  well  shown  in  Cooper's  Illustrations  of  Diseases  of  the 
Breast,  pi.  i;  and  a  full  account  of  all  the  diseases  of  this  class  is  given  by  Mr.  Birkett  in 
his  work  already  cited. 

§  Two  such  cases  are  described  by  Sir  B.  C.  Brodie  (Lectures  on  Pathology  and  Surgery, 
p.  139). 


364  SEKOUS     CYSTS. 

think  it  is  more  commonly  concurrent  with  a  contracted  and  partially 
indurated  state  of  the  gland ;  a  state  which,  independent  of  the  cysts, 
appears  similar  to  cirrhosis  of  the  liver,  and  has,  I  think,  been  named 
cirrhosis  of  the  mammary  gland.  Its  coincidence  with  cysts  proves  its 
nearer  relation  to  that  shrivelled  and  contracted  state  of  the  granular 
kidney  with  which  the  renal  cysts  are  so  commonly  connected ;  or  (when 
the  cysts  are  formed  by  partial  dilatation  of  the  ducts),  to  the  shrivelled, 
indurated  state  of  the  lung  that  may  coincide  with  dilatation  of  the 
bronchi. 

The  cysts  in  these  cases  are  usually  of  small  size,  thin-walled,  full 
of  yellow,  brown,  green,  and  variously  deep-colored  fluids ;  fluids  that 
are  usually  turbid,  various  in  tinge  and  density,  but  not  usually  much 
denser  than  serum.  They  do  not  lie  in  groups,  but  are  scattered 
through,  it  may  be,  the  whole  extent  of  the  gland ;  and  their  walls, 
though  thin,  are  tough  and  tense,  and  very  closely  adherent  to  the  sur- 
rounding gland-substance.  Similar  small  cysts  are  sometimes  found  in 
connection  with  hard  cancer  of  the  breast ;  and  in  this  case  they  have 
been  called  by  Mr.  Hunter  and  others  "  cancerous  hydatids  ;"  but  their 
proper  relation  in  such  cases  appears  to  be,  not  with  the  cancer,  but 
with  the  coincidently  shrivelled  gland. 

In  this  disease  of  the  mammary  gland  there  is  no  reason  to  believe 
a  malignant  nature,  though  the  coincidence  with  cancer  appears  not 
rare.  Yet  the  diagnosis  between  it  and  cancer  is  not  always  clear,  and 
many  breasts  have  been  removed  in  this  uncertainty.  I  once  saw  such 
a  case,  and  it  ended  fatally.  A  woman,  fifty  years  old,  had,  in  her  left 
breast,  just  below  the  surface  of  the  mammary  gland,  a  small,  smooth, 
oval,  and  movable  tumor.  It  felt  firm,  but  not  hard  ;  but,  external  to 
it,  in  a  line  extending  towards  the  axilla,  were  two  or  three  small  round 
"knots,"  scarcely  so  large  as  peas,  and  quite  hard.  In  the  axilla  was 
an  enlarged  gland.  The  breast  was  soft,  flaccid,  and  pendulous.  The 
tumor  was  sometimes  painful,  and  a  serous  and  bloody  fluid  often  flowed 
from  the  nipple.  The  patient's  youngest  child  was  sixteen  years  old, 
and  the  tumor  had  been  noticed  six  months,  having  arisen  without  evi- 
dent cause.  There  was  doubt  enough  about  the  diagnosis  of  this  case 
to  suggest  that  the  tumor  should  first  be  cut  into.  An  incision  exposed 
the  cavity  of  a  cyst  full  of  dark,  turbid,  greenish  fluid,  and  near  it 
many  more  cysts.  Similar  cysts  pervaded  the  whole  extent  of  the 
gland,  and  the  whole  breast  was  therefore  removed.  Many  of  the  cysts 
communicated  with  lactiferous  tubes,  from  which  bristles  could  be  passed 
through  the  nipple.* 

In  this  case  one  comparatively  large  cyst  existed,  with  many  of  much 
smaller  size.  In  more  usual  cases  one  cyst  has  a  yet  greater  predomi- 
nance over  others,  or  even  exists  alone.     Sometimes,  in  such  instances, 

*  In  the  Museum  of  the  Middlesex  Hospital  is  a  breast  from  a  woman  in  whom  both 
mammary  glands  were  thus  diseased.  In  the  College  Museum,  Nos.  150  and  152  best  illus- 
trate the  disease. 


SYNOVIAL    CYSTS.  365 

the  removal  or  laying  open  of  one  large  cyst  has  been  sufficient ;  but  in 
some,  smaller  cysts  neglected  have  enlarged,  and  the  disease  has  ap- 
peared to  recur.* 

The  single  cysts  of  the  mammary  gland  may  become  enormous.  I 
know  not  what  boundary  may  be  set  to  their  possible  size ;  but  I  find 
one  case  in  which  nine  pounds  of  limpid  "serosity"  were  produced  in 
three  months  in  the  breast  of  a  woman  thirty  years  old.f  In  this  case 
the  walls  of  the  cyst  were  thin,  and  the  fluid  serous ;  and  the  fact 
illustrates  a  general  rule,  that  the  cysts  which  contain  the  simplest 
fluids,  and  which  have  the  simplest  walls,  are  apt  to  grow  to  the  largest 
size  :  thickening  of  cyst-walls,  and,  much  more,  their  calcification,  J 
are  here,  as  elsewhere,  signs  of  degeneracy,  and  of  loss  of  productive 
power. 

It  would  appear  as  if  any  cyst  of  the  mammary  gland  might,  after 
some  time  of  existence  in  the  barren  state,  become  prolific,  and  bear 
on  its  inner  surface  growths  of  glandular  or  other  tissue.  But  of  these 
proliferous  cysts  I  will  speak  in  the  next  lecture.  § 

3.  Of  Synovial  Cysts  I  need  say  very  little.  Under  the  name  may 
be  included  all  the  anormal  bursse,  or  ganglions,  as  they  are  called.  In 
these,  again,  two  methods  of  formation  probably  obtain.  Some,  of 
which  the  best  example  is  the  bursa  over  the  patella  and  its  ligament, 
are  merely  enlargements,  with  various  transformations,  of  bursse  natur- 
ally existing.  Not  materially  different  from  these  are  the  bursse  which 
form  anew  in  parts  subjected  to  occasional  localized  pressure,  and  which 
appear  to  rise,  essentially,  from  the  widening  of  spaces  in  the  areolar 
form  of  connective  tissue,  and  the  subsequent  levelling  or  smoothing  of 
the  boundaries  of  these  spaces.  But  others,  such  as  the  bursas  or  gan- 
glions which  form  about  the  sheaths  of  the  tendons  at  the  wrist,  appear 
to  be  the  cystic  transformations  of  the  cells  inclosed  in  the  fringe-like 
processes  of  the  synovial  membrane  of  the  sheaths.  The  opportunities 
of  dissecting  these  are  rare  ;  but  I  believe  there  is  a  close  resemblance, 
in  mode  of  formation,  between  them  and  the  cysts  of  the  choroid  plexus. 

*  Sir  B.  C.  Brodie,  loc.  cit.  p.  146,  note. 

I  Case  by  M.  Marini,  cited  by  M.  Berard,  "  Diagnostic  differentiel  des  Tumeurs  do 
Sein,"  p.  86. 

J  For  a  case  in  which  the  walls  of  a  cyst  in  the  breast  ^vere  calcified,  and  crackled  like 
those  of  ossified  arteries,  when  pressed,  see  Berard,  loc.  cit.  p.  56  ;  and  for  a  similar  calca- 
reous degeneration  of  the  wall  of  an  ovarian  cyst,  reference  may  be  made  to  a  case  of 
separated  and  transplanted  ovary,  recorded  by  the  editor  in  the  Ed  Med.  Jal.,  Feb.  1861. 

§  Having  in  view  only  the  illustration  of  the  more  general  pathology  of  these  cysts,  I  have 
not  referred  to  more  special  instances  of  them.  Examples  enough  are  to  be  found  in  all  the 
works  here  quoted.  Neither  have  1  mentioned  any  analysis  of  the  contents  of  serous  cysts  ; 
for  few  have  been  made,  and  these  few  were  made  on  such  various  materials,  that  no 
general  account  of  them  can  be  rendered.  Several  are  cited  in  Simon's  Medical  Chemistry  ; 
and  in  Frerichs'  Ueber  Gallert-  oder  CoUoidgeschwiilste,  pp.  7-9,  &c.;  and  by  Virchow,  in 
the  Verhandlungen  der  med.-phys.  Gessellsch.  in  Wiirzburg,  B.  ii,  p.  281.  See  also,  on  the 
contents  of  ovarian  cysts.  Dr.  Tilt's  papers  in  the  Lancet,  June,  1850. 


366  MUCOUS     CYSTS. 

Rokitansky  has  shown  that  these  are  due  to  cystic  growth  in  the  villi 
appended  to  the  margins  of  the  plexus,  which  villi  are  very  similar,  in 
their  constituent  structures,  to  the  processes  of  the  synovial  fringes. 
And  the  probability  of  similar  origin  is  enhanced  by  the  likeness  of  the 
contents  of  the  cysts,  in  both  cases,  to  the  fluids  secreted  by  the  fringes 
in  the  normal  state.* 

4.  Under  the  name  of  Mucous  Cysts  we  may  include  all  such  as  are 
formed  in  connection  with  simple  mucous  membranes,  or  Avith  glandular 
structures  which  we  call  mucous,  while  Ave  know  no  other  or  peculiar 
office  served  by  their  secretions. 

There  may  be  many  cysts  of  this  kind ;  but  the  best  examples  appear 
to  be  those  that  may  be  named  Nabothian  and  Cowperian  cysts.  The 
former  probably  originate  in  cystic  degeneration  of  the  glands  of  the 
mucous  membrane  about  the  cervix  uteri.  Protruding,  either  alone,  or 
with  polypoid  outgrowths  of  the  mucous  membrane,  they  are  observed 
successively  enlarging,  then  bursting  and  discharging  their  mucous 
contents,  and  then  replaced  by  others  following  the  same  morbid  course. 
Or,  instead  of  clusters  of  such  cysts,  one  alone  of  larger  size  and 
simpler  structure  may  be  found,  f 

The  Cowperian  cysts  appear  to  be  connected  with  the  Cowper's, 
Bartholin's  or  Duverney's  glands  in  the  female.  Whether  arising  from 
dilatation  of  the  duct,  or  from  cystic  transformation  of  the  elementary 
structures  of  the  gland,  cannot  be  yet  stated ;  but,  in  the  exact  posi- 
tion of  the  Bartholin's  gland,  and  projecting  into  the  vagina  near  its 
orifice,  a  cyst  is  often  found,  of  regular  oval  shape,  thin-walled,  of  un- 
certain size,  but  growing  sometimes  to  the  capacity  of  a  pint.  Com- 
monly the  contents  of  such  a  cyst  are  a  colorless,  pellucid,  or  opaline 
ropy  fluid,  like  that  found  in  the  closed-up  gall-bladder.  But  from 
this  they  often  vary.  I  have  seen  the  contents  of  such  cysts  like  the 
ink  of  the  cuttle-fish,  like  the  fluid  of  melanotic  tumors,  and  like  thick 
turbid  coff'ee ;  or,  to  the  sight,  they  may  exactly  resemble  fluid  faecal 
matter. I  Moreover,  these  cysts  are  very  apt  to  inflame  and  suppurate. 
Many  abscesses  projecting  into  the  vagina  have  in  these  their  origin ; 
and  the  treatment  these  abscesses  receive,  by  free  incision,  is,  I  believe, 
appropriate  for  the  cysts  under  all  conditions. 

It  is  not  apparent  upon  what  the  varieties  in  the  contents  of  these 

*  In  a  communication  in  the  Mem.  de  I'Acad.  de  Med.  t.  xvi,  1S52,  M.  Gosselin  has 
described  (in  addition  to  the  distension  of  the  sheaths  of  the  tendons  by  increased  secretion 
of  synovia),  the  formation  of  "  ganglions"  by  the  dilatation  after  obstruction  of  the  mouths  of 
follicles,  which  normally  open  into  the  cavity  of  the  joint.  The  ganglions  are  therefore  in 
such  cases  subsynovial  cysts.  For  an  account  of  the  loose  bodies  which  form  in  these  cysts, 
a  paper  by  Lebert  in  the  C.  R.  de  la  Soc.  de  Biologie,  t.  iv,  p.  89,  may  be  referred  to. 

■f"  A  remarkable  example  of  a  cyst,  thus,  I  suppose,  originating,  is  in  the  Museum  of  the 
Middlesex  Hospital. 

J  As  in  a  case  related  by  Mr.  Csesar  Hawkins  in  his  Lectures,  Medical  Gazette,  vol.  xxi ; 
and  in  two  cases  by  Lebert,  Abhandluugen,  p.  109. 


SANGUINEOUS    CYSTS.  367 

cysts  depend.  The  only  instances  that  I  could  minutely  examine  were 
the  two  following :  In  the  first,  a  woman,  25  years  old,  under  the  care 
of  Dr.  West,  had  a  smooth  oval  swelling  in  the  lower  and  fore  part  of 
the  right  labium,  projecting  on  its  inner  surface,  and  nearly  an  inch  in 
diameter.  This  had  been  observed  slowly  increasing  for  six  years,  and 
had  commenced  three  months  after  partui'ition.  It  was  not  painful.  I 
punctured  it,  and  let  out  about  three  drachms  of  pellucid  fluid,  like 
mucus,  or  the  white  of  egg.  The  cyst  had  a  polished  white  internal 
surface,  and  the  fluid  contained  numerous  corpuscles,  like  very  large 
white  blood-corpuscles,  and  like  such  as  are  commonly  found  in  the 
tenacious  fluid  of  bursae.  The  cyst  closed  on  the  healing  of  the  wound  : 
but  two  years  afterwards  either  it,  or  some  other  part  of  the  gland  simi- 
larly diseased,  appeared  again. 

In  the  other  case,  the  patient  was  forty-five  years  old,  and  under  the 
care  of  Mr.  Stanley.  The  tumor  was  nearly  regularly  oval,  occupying 
the  whole  length  of  the  right  labium,  and  obstructing  the  vagina.  She 
had  observed  it  increasing  for  four  years  :  it  was  painless,  but  had  been 
often  struck.  A  free  incision  gave  issue  to  about  fourteen  ounces  of 
thick,  inodorous,  dark  brown  fluid,  like  turbid  coff"ee.  The  walls  of  the 
cyst  were  about  one-third  of  a  line  thick,  tough,  compact,  and  closely 
connected  with  the  surrounding  tissues.  Mr.  Abernethy  Kingdon, 
who  examined  the  contents,  found  abundant  molecular  matter,  and  gra- 
nule-masses, together  with  groups  of  cells,  apparently  resembling  epithe- 
lial cells  of  various  sizes. 

5.  The  Sanguineous  Cysts,  or  cysts  containing  blood,  are  probably, 
in  many  instances,  very  nearly  related  to  the  serous.  Some  may  be 
explained  by  an  accidental  hemorrhage  into  the  cavity  of  a  serous  cyst ; 
an  event  corresponding  with  the  transformation  of  a  common  hydrocele 
into  an  hsematocele.  The  contents  of  some  of  these  cysts  are,  indeed, 
just  like  those  of  an  hsematocele,  with  fluid  and  coagulated  and  variously 
decolorized  blood.*  But  some  cysts  appear,  from  their  origin,  to  con- 
tain blood;  and  this  blood,  I  think,  always  remains  fluid  till  it  is  let  out, 
while  that  which  collects  by  hemorrhage  into  a  serous  cyst  is  generally 
partially  or  wholly  coagulated.  Some  of  these  cysts  with  blood  are 
found  in  the  same  positions  and  circumstances  as  the  serous.  Thus,  in 
the  neck,  a  series  of  cases  of  blood-cysts  might  be  collected,  exactly 
corresponding  with  the  serous  cysts  in  that  part,  and,  like  them,  pro- 
bably derived  from  various  origins,  some  lying  in  the  thyroid  gland, 
some  near  it,  some  traceable  to  connection  with  vascular  naevi,  some  of 
proper  origin. 

Of  the  last  class  one  appeared  to  be,  which  was  in  St.  Bartholomew's 
Hospital  several  years  ago.     A  lad,  about  sixteen  years  old,  was  under 

*  Such  hemorrhages  are  frequent  in  cysts  of  the  thyroid  gland  (Frerichs;  Rokitansky  ; 
Museum  of  the  College  of  Surgeons,  1502).  Thus  also,  we  may  explain  the  liEematoceles 
of  the  spermatic  cord,  as  in  Mus.  Coll.  Surg.  2460  ;  and  Mus.  Bartholomew's,  Ser.  xxviii,  1 1 


368  SANGUINEOUS    CYSTS. 

Mr.  Stanley's  care,  with  a  large  oval,  and  somewhat  pendulous  swell- 
ing in  the  left  side  of  the  neck,  which  had  existed  many  years,  and 
appeared  merely  subcutaneous.  It  Avas  punctured,  and  about  sixteen 
ounces  of  fluid  blood  escaped,  which  soon  coagulated.  After  this  the 
cyst  closed  ;  a  result  more  favorable  than  may  generally  be  anticipated 
from  such  simple  treatment :  for  usually  these,  like  other  cysts,  are  not 
obliterated  unless  after  free  incision. 

In  the  parotid  gland,  also,  cysts  containing  fluid  blood  have  peculiar 
interest.  In  1848,  I  assisted  Mr.  Stanley  in  the  removal  of  one  which 
lay  quite  within  the  parotid  of  a  gentleman  about  40  years  old.  It  had 
been  for  some  years  increasing  in  size,  and  lay  beneath  some  branches 
of  the  facial  nerve,  from  which  the  need  of  separating  it  without  injury 
made  its  removal  very  difl&cult.  This,  however,  was  safely  accomplished, 
and  the  patient  remains  well. 

At  nearly  the  same  time,  a  man,  25  years  old,  was  under  my  care 
with  a  similar  cyst,  which  had  been  increasing  without  pain  for  two 
years.  It  lay  in  the  parotid,  but  very  near  its  surface.  I  punctured 
it,  and  evacuated  two  or  three  drachms  of  bloody-looking  fluid,  with 
some  grumous  and  flocculent  paler  substance  intermingled.  This  fluid 
coagulated  like  blood,  and  contained  blood-cells,  much  free  granular 
matter,  crystals  of  cholesterine,  and  what  appeared  to  be  white  corpus- 
cles of  blood  acquiring  the  character  of  granule-cells.  The  cyst  filled 
again  with  similar  fluid  after  being  thus  evacuated  :  I  therefore  dis- 
sected it  from  the  parotid  gland,  and  the  patient  recovered. 

Occasionally  one  meets  with  sanguineous  cysts,  which  derive  a  pecu- 
liar aspect  from  a  columnar  or  fasciculated  structure  of  their  interior, 
making  them  look  like  the  right  auricle  of  a  heart.  This  was  singu- 
larly the  case  in  one  which  I  assisted  Mr.  Macilwain,  in  removing  from 
over  the  lower  angle  of  the  scapula  of  a  lad  fifteen  years  old.  It  had 
existed  more  than  eight  years,  and  grew  rapidly,  while,  in  the  last  year, 
he  was  actively  at  work.  It  was  now  also  painful.  It  felt  like  a  fatty 
tumor,  but  proved  to  be  a  cyst  thus  fasciculated  like  an  auricle,  with  a 
finely  polished  internal  surface,  and  containing  about  an  ounce  and  a 
half  of  liquid  blood.  Its  walls  were  from  one  to  two  lines  in  thickness, 
and  seemed  in  great  part  made  up  of  small  cells,  such  as  one  sees  in  a 
bronchocele,  full  of  serous  and  bloody  fluids.  No  trouble  followed  the 
operation,  and  the  patient  remains  well  twelve  years  after  it.* 

A  cyst  presenting  the  same  peculiarity  of  internal  surface  was  re- 
moved by  Mr.  Stanley,  in  October,  1848,  from  over  the  pubes  of  a  boy 
thirteen  years  old.  It  was  observed  increasing  for  nine  months,  and 
part  of  it,  consisting  of  a  simple  thin-walled  serous  cyst,  was  transpa- 
rent; but  behind,  and  projecting  into  this,  was  a  more  thickly-walled 
cyst,  containing  about  a  drachm  of  dark  liquid  blood,  and  on  its  surface 
fasciculate  and  polished  like  an  auricle.     Its  walls  were  well  defined, 

*  The  cyst  is  in  the  Museum  of  St.  Bartholomew's,  Ser.  xxxv,  38. 


COLLOID    CYSTS.  369 

formed  of  connective  tissue  imperfectly  filamentous  and  nucleated,  and 
I  could  find  no  epithelium  lining  it.     The  operation  was  successful. 

It  is  not  improbable,  I  think,  that  both  these  cases  may  have  had 
their  origin  in  vascular  nsevi,  like  other  cysts  containing  blood,  to  which 
I  shall  refer  in  speaking  of  erectile  tumors.  I  will  now  only  refer  to 
certain  cysts  which,  without  any  erectile  formation,  appear  to  be  de- 
rived from  portions  of  veins  dilated,  and  obstructed,  and  shut  ofi"  from 
the  stream  of  blood.  Such  a  one  was  removed  by  Mr.  Lloyd,  many 
years  ago,  from  a  man's  thigh.  It  lay  in  the  course  of  the  saphena 
vein ;  but  neither  that,  nor  any  other  considerable  vein,  was  divided  in 
the  operation,  or  could  be  traced  into  the  cyst.  This  cyst*  was  of 
spherical  form,  about  an  inch  and  a  half  in  diameter,  closed  on  all 
sides;  its  walls  were  tough,  and  polished  on  their  inner  surface  :  it  was 
full  of  dark  fluid  blood,  and  its  venous  character  was  manifested  by  two 
valves,  like  those  of  veins,  placed  on  its  inner  surface.  On  one  of 
these  a  soft  lobed  mass,  like  an  intra-cystic  growth,  is  seated,  f 

6.  Cysts  containing  oil  or  fatty  matter,  without  any  more  highly 
organized  substance,  are  very  rare.  Many  contain  fatty  matters  min- 
gled with  serous,  epithelial,  and  other  substances ;  but  in  these  the  fatty 
constituent  is  probably  the  result  of  the  degeneration  of  the  other  con- 
tents. Some,  however,  appear  to  contain  fatty  matter  alone.  Mr.  Hun- 
ter preserved  a  specimen|  of  what  he  marked  as  "  oil  from  an  adipose 
encysted  tumor,"  It  was  taken,  I  believe,  from  a  cyst  that  grew  "be- 
tween the  bony  orbit  and  the  upper  eyelid  "  of  a  young  gentleman. 
When  recent,  it  was  described  as  "  pure  oil,  perfectly  clear  and  sweet, 
which  burnt  with  a  very  clear  light,  and  did  not  mix  with  aqueous 
fluids,  and,  when  exposed  to  cold,  became  as  solid  as  the  human  fat." 

In  1850  Mr.  Wormald  removed  a  small  cyst  from  a  woman's  breast, 
the  contents  of  which  appeared  to  be  pure  oily  matter,  that  congealed 
into  a  substance  like  lard,  and  contained  crystals  of  margarine,  but  no 
organized  corpuscles.  The  patient  remains  well.  Schuh§  relates  two 
cases  of  cysts  under  the  brow,  which  contained  similar  oily  matter,  and 
whose  walls  had  all  the  structures  of  skin,  with  implanted  hairs. 

7.  Colloid  Cysts  are,  at  present,  a  very  ill-defined  group ;  the  term 
"colloid"  being  used  by  Frerichs,||  and  other  recent  German  writers, 
for  all  those  morbid  materials  that  are  pellucid,  jelly-like,  flickering, 
half  solid,  or  more  or  less  closely  resembling  the  material  found  in  gela- 
tiniform,  alveolar,  or  colloid  cancer.     Such  a  material  is  common  in 

*  Museum  of  St.  Bartholomew's  Hospital,  Appendix,  10. 

f  In  the  Museum  of  King's  College  is  a  large  cyst  removed  from  a  thigh,  into  which  it  is 
said  the  saphena  vein  opened. 

X  Mus.  Coll.  Surg.,  181  :  Pathological  Catalogue,  vol.  iv,  p.  177. 
§  Ueber  .  .  .   Pseudoplasmen,  p.  144. 
11   Ueber  Gallert-  oder  Colloidgeschwtilste. 


370  SEMINAL    CYSTS. 

the  cysts  of  bronchoceles,  and  in  those  of  the  kidney ;  especially,  I 
think,  in  those  which  are  not  associated  with  contraction  of  the  renal 
substance,  and  which  Baillie,  and  other  writers  of  his  time,  described 
as  hydatid  disease  of  the  kidney. 

The  contents  of  these  cysts  may  present  the  most  diverse  conditions ; 
maybe  of  all  densities,  from  that  of  dilute  serum  to  that  of  a  firm  jelly ; 
may  range  between  pellucidity  and  the  thickest  turbidness;  may  be  of 
all  hues  of  yellow,  olive-green,  orange,  brown,  pink,  or  neaidy  black. 
The  thick  and  pellucid  contents  of  such  renal  cysts  are  enumerated  as 
examples  of  colloid  matter ;  so  are  the  contents  of  ranulse,  and  of  many 
bursae ;  but  the  type  is  the  material  of  the  so-called  colloid  cancer. 
This,  however,  is  beyond  my  present  range;  and  I  pass  by  it,  referring 
only  to  the  already  cited  works  of  Frerichs  and  Rokitansky,  and  to 
that  of  Bruch,*  for  the  best  information  yet  supplied. 

8.  The  last  group  of  cysts  of  which  I  shall  now  speak  includes  such 
as  contain  secreted  fluids,  like  those  of  the  glands,  by  the  dilated  ducts 
or  transformed  elements  of  which  they  are  formed.  Such  are  the  cysts 
in  the  breast  that  contain  milk,  and  probably  many  instances  of  ranula. 
The  origin  of  the  former  is,  probably,  in  dilatation  of  lactiferous  ducts ; 
that  of  the  latter  is  uncertain.  But  the  examples  of  this  group,  of 
which  I  wish  more  particularly  to  speak,  are  the  Seminal  Cysts,  in- 
cluding under  this  name  those  that  are  usually  called  encysted  hydro- 
celes, or  hydroceles  of  the  spermatic  cord.f  Their  various  forms  are 
fully  described  by  Mr.  Curling,|  and  are  well  illustrated  by  specimens 
in  the  Museum  of  the  College. §  They  are  usually  thin-walled  spherical 
or  oval  cysts,  imbedded  in,  and  loosely  connected  with,  the  tissue  of 
the  cord.  They  may  occur  singly,  or  in  a  group.  Their  most  frequent 
seat  is  just  above  the  epididymis,  but  they  may  be  found  in  any  part  of 
the  spermatic  cord.  Their  walls  are  formed  of  connective  tissue,  and 
they  may  be  lined  with  delicate  tessellated  epithelium.  Their  contents 
are  usually  a  colorless  slightly  opaline  fluid,  like  water  with  which  a 
little  milk  has  been  mingled. 

The  discovery  was  made  at  the  same  time,  and  independently,  by 
Mr.  Lloyd  and  Mr.  Listen,  ||  that  the  fluid  obtained  from  these  cysts 

*  Ueber  Carcinoma  alveolare  und  den  alveolaren  Gewebstypus ;  in  Henle  and  Pfenfer's 
Zeitschrift,  vii,  1849. 

f  Hydroceles  of  the  spermatic  cord  are  not  in  all  cases  necessarily  seminal  cysts.  For  it 
sometimes  happens  that  in  infants  the  canalis  vaginalis,  although  closing  np  at  both  ends, 
yet  does  not  become  obliterated  along  its  entire  extent.  In  snch  cases  fluid  may  collect  in 
the  interior  of  the  canal,  but  such  fluid  has  simply  the  characters  of  that  of  a  common 
hydrocele.  In  females  similar  collections  of  fluid  may  take  place  in  the  canal  of  Nuck 
along  the  course  of  the  round  ligament.  Along  with  these  may  be  mentioned  those  very 
rare  cases  in  which  such  hydroceles  of  the  cord,  through  the  upper  end  of  the  canalis 
vaginalis  remaining  open,  communicate  with  the  peritoneal  cavity. 

J  Treatise  on  Diseases  of  the  Testis,  &c. 

i   Especially  Nos.  2456  to  2459. 

II  Medico-Chirurgical  Trans.,  vol.  xxvi,  pp.  216  and  -368.  See  also,  a  paper  by  Mr. 
Curling,  in  the  Monthly  Journal  of  Med.  Science,  x,  p.  1023. 


SEMINAL     CYSTS.  371 

usually  contains  the  seminal  filaments  or  spermatozoa.  Repeated  ob- 
servations have  confirmed  their  discovery ;  and  both  the  existence  of 
these  bodies,  and  the  usual  characters  of  the  fluid,  justify  the  speaking 
of  it  as  a  diluted  or  imperfect  seminal  fluid,  and,  therefore,  of  the  cysts 
as  "  seminal  cysts." 

It  was  my  lot,  I  believe,  first  to  dissect  some  of  these  cysts  ;*  and  I 
found  that  they  had  no  open  communication  or  other  connection  with 
any  part  of  the  secretory  apparatus  of  the  testicle,  and  that  their  re- 
lation to  the  epididymis,  on  which  they  lay,  was  such  as  to  forbid  the 
supposition  of  the  seminal  secretion  being  transmitted  to  them  from  the 
tubes.  I  suggested,  therefore,  that  these  cysts  were  formed  quite  in- 
dependently of  the  tubes ;  and  that,  being  seated  near  the  organ  that 
naturally  secretes  the  semen,  they  possessed  a  power  of  secreting  a 
similar  fluid  ;  just  as  cysts  beneath  the  hairy  parts  of  the  body  may 
produce  hair  and  epidermis,  and  the  ordinary  products  of  the  skin. 
The  explanation  was,  I  believe,  deemed,  unsatisfactory ;  but  it  is  sup- 
ported by  the  later  investigations  of  other  cysts,  especially  of  those  to 
which  I  have  already  referred,  growing  in  the  thyroid  and  mammary 
glands.  While  we  find  in  these  that  perfect  gland-substance  may  grow 
from  the  cyst-walls,  it  cannot  seem  singular  if,  in  a  cyst  lying  near  the 
testicle  or  its  duct,  materials  like  the  secretion  of  the  testicle  should  be 
formed.  The  growth  and  nutrition  of  gland-tissue,  and  the  formation 
of  gland-secretion,  are  so  truly  parts  of  one  process,  that  the  proof  of 
the  former  occurring  in  one  group  of  cysts  removes  all  improbability 
from  the  belief  that  the  latter  may  occur  in  another  group. 

If,  then,  we  may  regard  these  seminal  cysts  as  autogenous,  and  may 
arrange  them  with  those  of  the  kidney  and  other  glands  which  are  de- 
rived from  the  transformation  and  overgrowth  of  isolated  nuclei  or  cells, 
they  may  supply  some  facts  of  interest  to  the  general  pathology  of 
cysts.  Especially,  we  may  observe  that  in  diff"erent  specimens  of  these 
"hydroceles  of  the  cord,"  or  in  the  same  at  different  times,  the  con- 
tents may  be  either  a  seminal  fluid  or  an  ordinary  serous  fluid.  In  one 
of  the  cases  in  which  I  dissected  a  seminal  cyst,  there  existed,  besides 
that  which  contained  seminal  fluid,  another  larger  cyst,  above  and 
separate  from  the  testicle  and  tunica  vaginalis  ;  but  this  contained  only 
serous  fluid  like  that  of  a  common  hydrocele. f     Now  this  diversity  is 

*  Medico^Chirurgical  Transactions,  vol.  xxvii,  p.  398. 

f  Much  has  been  done  of  late,  through  more  careful  inquiries  into  the  structure  of  the" 
spermatic  cord,  to  throw  new  light  upon  the  mode  of  formation  of  the  cysts  connected  with 
it.  The  observations  more  especially  of  Luschka  (Virchow"s  Archiv,  p.  -310,  1854),  on  the 
structure  and  mode  of  formation  of  the  cysts  of  Morgagni,  and  the  discovery  by  Giraldes 
(Gaz.  des  Hopitaux,  Avril  17,  1858  ;  Proc.  Roy.  Soc.  Lond.,  May  6,  18-58)  of  certain  struc- 
tures, which  he  has  described  under  the  name  of  "Corps  Innomine,"  situated  behind  the 
tunica  vaginalis,  between  it  and  the  spermatic  vessels,  have  shown  that  there  exist  in  the 
cord  throughout  life,  more  or  less  atrophied,  remains  of  the  Wolffian  body  of  the  fcEtus. 
These  consist  of  small  vesicles  and  convoluted  tubules,  which  latter  are  short  and  tortuous, 
and  beset  with  varicose  dilatations.  Both  the  hydatids  of  Morgagni,  and  the  vesicles  and 
ccEcal  tubes  of  the  organ  of  Giraldes,  may  undergo  a  dilatation  into  cysts.     Luschka  has 


372  SEMINAL    CYSTS. 

common  among  cysts.  Those  in  the  kidney  may  contain  the  materials 
of  urine,  but  they  more  commonly  do  not ;  those  of  the  lactiferous 
tubes  may  contain  either  milk  or  some  form  of  serous  fluid ;  ovarian 
cysts  may  at  one  period  produce  hair  and  the  other  growths  and  secre- 
tions from  skin,  and  then,  casting  off  these,  they  may  produce  only 
serous  or  some  other  fluid. 

In  difi"erent  cysts,  this  diversity  of  contents  may  sometimes  depend 
on  diff'erence  of  origin  or  of  early  construction.  But  when  it  happens 
in  difi'erent  periods  of  the  same  cyst,  it  illustrates  the  general  rule  that, 
in  the  course  of  time,  cysts  are  apt  to  degenerate,  and  to  produce  less 
and  less  highly  organized  substances  or  secretions.  This  degeneration 
does  not  take  place  in  any  certain  time ;  but  generally,  the  larger  a  cyst 
grows,  the  less  organized  are  its  products ;  as  if  nearly  all  the  forma- 
tive force  were  expended  in  growth,  and  little  remained  available  for 
secretion.  Generally,  also,  the  longer  a  cyst  has  lived,  the  less  orga- 
nized are  its  products.  However,  both  these  rules  are  only  general. 
I  met  with  a  remarkable  exception  to  them  in  a  seminal  cyst,  which  had 
existed  for  seven  or  eight  years  in  a  man  more  than  70  years  old.  I 
withdrew  from  it  eighteen  ounces  of  fluid  laden  with  seminal  filaments ; 
and  no  fresh  accumulation  took  place  in  the  two  years  following  the 
operation.  In  another  case,  of  four  years'  duration,  Mr.  Stanley  re- 
moved from  a  cyst  on  the  right  side  of  the  scrotum  25  ounces  of  such 
fluid,  and  from  one  on  the  left  side  46  ounces. 

I  have  spoken  of  these  seminal  cysts  as  separate  from  the  testicle 
and  tunica  vaginalis.  Mr.  Lloyd  believed  that,  in  some  cases,  he  ob- 
tained fluid  containing  spermatozoa  from  hydroceles  of  the  tunica  vagi- 
nalis; and  his  belief  was  lately  confirmed  by  the  examination  of  a  case 
after  death.  The  specimen  presents  the  ordinary  appearances  of  a 
common  hydrocele,  except  that  the  inner  surface  of  the  tunica  vaginalis 
is  uneven,  with  a  few  small  depressions  or  pouches  from  it.  This  hydro- 
cele had  been  repeatedly  tapped;  the  fluid  had  always  the  ordinary 
serous  appearance  of  that  of  common  hydrocele ;  but  it  always  con- 
tained abundant  seminal  filaments.  Can  we  suppose,  then,  that  the 
tunica  vaginalis  has  the  power  of  secreting  seminal  fluid?  or,  were 
there  in  this  case  minute  secreting  cysts,  which,  by  dehiscence,  dis- 
charged their  seminal  fluid  into  the  cavity  of  the  tunica  vaginalis,  as 
sometimes  ovarian  cysts  by  spontaneous  openings  discharge  their  con- 
tents into  one  another,  or  into  the  cavity  of  a  parent  cyst  ?*     I  am 

pointed  out  that  the  former  of  these  not  unfrequently  communicate  with  the  spermatic  canal, 
and  contain  accordingly  spermatozoa.  It  may  easily  be  understood,  therefore,  that  when 
such  an  hydatid  increases  so  as  to  form  an  encysted  hydrocele,  that  the  fluid  it  contains 
should  liave  seminal  filaments  floating  in  it.  But  as  others  of  these  hydatids  do  not  com- 
municate with  the  spermatic  canal,  they,  in  their  cystic  enlargement,  will  most  probably 
contain  a  fluid  difiering  in  nothing  from  that  of  a  common  hydrocele. 

*  In  corroboration  of  the  opinion  expressed  in  the  text,  it  may  be  mentioned  that  it  is  not 
unusual,  in  examining  healthy  testicles,  to  find  projecting  from  the  sides  of  their  bodies  into 
the  cavity  of  the  tunica  vaginalis,  small  appendages.     They  are  mostly  situated  close  to  the 


COMPOUND     OR     PROLIFEROUS    CYSTS. 


373 


disposed  to  think  this  latter  explanation  the  more  probable ;  but  as  yet 
the  facts  are  too  few  to  justify  any  conclusion. 


LECTURE  XXIII. 


COMPOUND    OR    PROLIFEROUS   CYSTS. 


In  the  last  lecture  I  traced  and  illustrated  the  formation  of  simple 
or  barren  cysts, — the  cysts  that  have  only  liquid  contents.  Among 
these,  the  instances  of  the  highest  productive  power  appear  to  be  in  the 
cysts  that  secrete  a  seminal  fluid,  and  those  that  are  lined  with  a  com- 
plete secreting  epithelium.  In  the  present  lecture  I  propose  to  describe 
the  cysts  that  appear  to  have  the  power  of  producing  more  highly  organ- 
ized, and  even  vascular,  structures;  or,  as  they  may  be  generally 
named,  proliferous  cysts.* 

These  include  such  as  are  often  called  "  compound  cysts,"  or  ''  com- 
pound cystoid  growths ;"  but  I  would  avoid  these  terms,  because  they 
do  not  suggest  the  difference  be- 
tween the  cysts  with  endogenous  I'ig-  45. f 
growths,  and  those  that  may  ap- 
pear   equally   compound,    though 
they  are  only  simple   cysts  clus- 
tered or  grouped  together.     This 
difference  should  be  clearly  marked 
in  names,  for  it  generally  is  so  in 
nature.  In  an  ovary,  for  example, 
such  as  is  drawn  in  Fig.  45,  from 
a  specimen  in  St.  Bartholomew's 
Museum,  it  is  not  unfrequent  to 
find    many    small    cysts,   formed, 

apparently,  by  the  coincident  enlargement  of  separate  Graafian  vesi- 
cles4     These    lie  close   and  mutually   compressed;   and,    as  they  all 

line  of  reflection  of  the  serous  membrane.  Our  friend  Professor  Rolleston,  of  Oxford,  who 
has  carefully  examined  them,  writes  us  that  he  has  traced  tubuli  seminiferi  passing  into 
them  from  the  body  of  the  testis.  It  is  not  improbable  that  these  structures  may  at  times 
undergo  cystic  dilatation,  in  which  case,  should  dehiscence  of  the  cyst  through  any  cause 
occur,  seminal  fluid  would  be  discharged  into  the  sac  of  the  tunica  vaginalis. 

*  Under  this  name  are  here  included  the  sero-cystic  sarcomata  of  Sir  B.  C.  Brodie  (Lec- 
tures on  Pathology  and  Surgery) ;  most  of  the  specimens  of  Cysto-sarcoma  phyllodes  and 
proliferum  of  MuUer  (On  Cancer)  ;  and  most  of  the  tuberous  cystic  tumors  of  Mr.  Ctesar 
Hawkins  (Medical  Gazette,  vol.  xxi,  p.  951). 

f  Section  of  an  ovary  with  many  closely-placed  cysts  formed  by  enlargement  of  Graafian 
vesicles:  natural  size. 

J  An  observation  recently  made  by  Rokitansky  (Wiener.  Wochenblatt,  1855,  No.  1),  con- 
firms in  a  very  striking  manner,  the  truth  of  the  statement,  that  cystic  disease  of  the  ovary 
may  result  from  an  enlargement  of  the  Graafian  vesicles,  for  he  has  found,  in  a  case  of  in- 
cipient cystic  disease  of  the  ovary,  the  ovule  within  the  cyst. 


374  COMPOUND    OR    PROLIFEROUS     CYSTS. 

enlarge  together,  and,  sometimes,  by  the  wasting  of  their  partition  walls, 
come  into  communication,  they  may  at  length  look  like  a  single  many- 
chambered  cyst,  having  its  one  proper  wall  formed  by  the  extended 
fibrous  covering  of  the  ovary.  Many  multilocular  cysts,  as  they  are 
named,  are  only  groups  of  close-packed  single  cysts ;  though,  when  ex- 
amined in  late  periods  of  their  growth,  and,  especially,  when  one  of  the 
group  of  cysts  enlarges  much  more  than  the  rest,  it  may  be  difficult  to 
distinguish  them  from  some  of  the  proliferous  cysts.* 

Of  the  first  formation  of  cysts  that  may  be  proliferous  I  need  not 
speak ;  for,  so  far  as  is  at  present  known,  they  may  be  formed  exactly 
as  the  barren  cysts  are.  A  cyst  may  be  proliferous  in  whichever  of 
the  plans  described'in  the  last  lecture  it  may  have  had  its  origin.   Thus, 

1.  Bursas  formed  by  expansion  and  rarefying  of  areolar  spaces  may  be 
found  with  organized,  pendulous,  or  loose  growths  from  their  walls. f 

2.  Among  the  cysts  formed  by  growth  of  natural  cavities  or  obstructed 
ducts,  we  have  instances  of  surpassing  proliferous  power  in  the  ovarian 
cysts  from  Graafian  vesicles,  and  of  less  power  in  some  cases  of  dilated 
lactiferous  tubes  and  dilated  veins.^  And  3.  Among  the  autogenous 
cysts  we  find,  in  the  breast  and  other  glands,  some  of  the  principal  ex- 
amples from  which  the  following  history  of  proliferous  cysts  will  be 
derived. 

The  account  given  in  the  last  lecture  of  the  modes  of  origin  of  barren 
cysts  may  therefore,  so  far  as  the  cyst  is  concerned,  suffice  for  the 
proliferous  ;  and  I  shall  now  need  to  speak  of  only  the  intracystic  pro- 
ductions, the  difi'erences  of  which  may  decide  the  grouping  of  the  whole 
division  of  proliferous  cysts. 

*  This  may  perhaps  be  the  best  place  to  speak  of  that  form  of  cystic  disease  occurring  in 
the  neighborhood  of  the  ovary,  which  Ruysch  described  and  figured  long  ago,  as  an  hydatid 
affection  of  the  part.  The  cysts  in  these  cases  are  characterized  by  their  small  size,  com- 
monly that  of  a  pea,  and  rarely,  if  ever,  exceeding  an  egg  or  an  apple  ;  by  the  delicacy  of 
their  walls;  by  the  possession  usually  of  a  slender  pedicle,  and.  by  containing  a  serous  or 
slightly  gelatinous  fluid.  They  are  commonly  met  with  in  infants,  and  are  found  attached 
to  the  under  surface  of  the  outer  end  of  the  Fallopian  tube,  or  included  between  the  folds  of 
the  broad  ligament.  Recent  careful  inquiries  into  the  structure  of  these  parts  have  shown 
that  remains  of  the  Wolffian  body  of  the  foetus  exist  after  birth,  and  even  in  the  adult  female, 
lying  near  the  ovary  and  Fallopian  tube,  though  separable  from  them.  To  these  the  name 
of  par-ovarium,  or  organ  of  Rosenmiiller,  has  been  given.  Between  the  folds  of  the  broad 
ligament,  and  detached  from  the  organ  of  Rosenmiiller,  are  a  number  of  little"  grains,"  first 
described  by  Follin,  which  also  consist  of  remains  of  the  Wolffian  body.  The  small  simple 
cysts  referred  to  in  this  note  are  caused  by  dilatation  of  the  ccEcal  tubes  of  Gaertner,  of  which 
the  Wolffian  body  is  composed,  and  which  make  up  the  structure  of  the  organ  of  Rosen- 
muUer  and  the  grains  of  Follin.  The  cysts  in  these  cases,  therefore,  correspond  in  the 
female  with  those  already  described  in  the  spermatic  cord  in  the  male  in  connection  with 
the  organ  of  Giraldes.  See  especially  Verneuil  in  the  Mem.  de  laSoc.  de  Chirurgerie,  1854, 
vol.  iv. 

f  Museum  Coll.  Surg.,  367,  &c.  See  also,  a  case  by  Mr.  Caesar  Hawkins  (Medical  Ga- 
zette, vol.  xxi,  p.  951).  Perhaps,  also,  the  case  may  be  here  referred  to,  in  which  Mr. 
Hunter  found  loose  bodies  in  a  cavity  formed  round  the  ends  of  the  bones  in  an  ununited 
fracture  (Museum  Coll.  Surg.,  Nos.  469,  470). 

J  Museum  of  St.  Bartholomew's  Hospital,  Appendix  10;  and  see  previous  lecture. 


COMPLEX    OVARIAN    CYSTS. 


375 


1.  The  first  group  includes  the  cysts  which  have  others  growing  in 
or  upon  their  walls.  Of  these,  two  chief  examples  are  presented,  in  the 
complex  ovarian  cysts,  and  in  the  cystic  disease  of  the  chorion  or  "  hy- 
datid mole." 

The  principal  varieties  of  the  complex  ovarian  cysts  have  been  de- 
scribed to  the  very  life  by  Dr.  Hodgkin,  to  whom  we  are  indebted  for 
the  first  knowledge  of  their  true  pathology.*  But  since  his  minute  de- 
scription of  them  is,  or  should  be,  well  known,  I  will  more  briefly  say 
that,  according  to  his  arrangement,  we  may  find  in  these  proliferous 
ovarian  cysts  two  principal  or  extreme  forms  of  endogenous  cysts ; 
namely,  those  that  are  broad-based  and  spheroidal,  imitating  more  or 
less  the  characters  of  the  pa- 
rent cyst,  and  those  that  are  -^'^"  ^""^ 
slender,  pedunculated,  clus- 
tered, and  thin-walled.  Be- 
tween these  forms,  indeed, 
many  transitional  and  many 
mixed  forms  may  be  found ; 
yet  it  is  convenient  to  distin- 
guish the  two  extremes. 

A  typical  example  of  the 
first  is  in  the  College  Museum, | 
and  is  sketched  in  Fig.  46.  It 
is  an  Hunterian  specimen  ;  and 
the  mode  of  preparation  shows 
that  Mr.  Hunter  had  clearly 
apprehended  the  peculiarities 
of  its  structure.  It  is  a  large 
cyst,  with  tough,  compact,  and 
laminated  walls,  polished  on 
both  their  surfaces.  On  its 
inner    surface    there    project, 

with  broad  bases,  many  smaller  cysts,  of  various  sizes,  and  variously 
grouped  and  accumulated.  These  nearly  fill  the  cavity  of  the  parent 
cyst :  many  of  them  are  globular  ;  many  deviate  from  the  globular 
form  through  mutual  compression;  and  within  many  of  them  are  similar 
but  more  thinly-walled  cysts  of  a  third  order. 

Here  the  endogenous  cysts,  projecting  inwards,  appear  to  have  nearly 
filled  the  cavity  of  the  principal  or  parent  cyst ;  and  this  filling  up  is 
complete  in  another  specimen,  in  which  there  remains,  in  the  middle  of 
the  parent  cyst,  only  a  narrow  space  bounded  by  the  endogenous  cysts 
converging  in  their  growth  from  all  parts  of  the  parent  walls. 


*  Med.-Chir.  Trans.,  xv,  256 ;  and  Lectures  on  the  Morbid  Anatomy  of  Serous  Mem- 
branes, p.  221,  et  seq. 

f  Fig.  46,  section  of  a  proliferous  ovarian  cyst,  described  in  the  text :  about  one-third  of 
the  natural  size.  J  No.  166. 


376 


COMPLEX    OVARIAN     CYSTS. 


For  a  typical  example  of  the  slender,  thin-walled,  pedunculated,  and 
clustered  form  of  endogeneous  cysts,  I  may  adduce  the  specimen  from 
the  Museum  of  St.  Bartholomew's  Hospital,*  which  is  drawn  in  Fig. 47. 
It  shows  part  of  the  thick  laminated  wall  of  an  ovarian  cyst,  the  inner 

surface    of    which    is     thickly 
Fig.  47. t  covered  with  crowds  of  pyriform 

and  leaf-like  pellucid  vesicles, 
heaped  together,  and  one  above 
another.  This  is  a  compara- 
tively simple  specimen  of  the 
kind :  in  the  more  complex,  the 
endogenous  cysts  or  vesicles  are 
multiplied  a  thousand  fold,  and 
clustered  in  large  lobed  and 
warty -looking  masses  that  near- 
ly fill  the  cavity  of  the  cyst. 
Specimens  of  this  kind  are 
among  the  most  valuable  pos- 
sessions of  the  Museum  of  Guy's 
Hospital. 

The  College  Museum  fur- 
nishes specimens  of  the  forms 
intermediate  between  these  ex- 
tremes, |  in  which  the  endoge- 
nous cysts  of  the  second  and 
third  orders  have  walls  that  are 
not  pellucid,  yet  are  thin  and  vascular,  and  are  attached  by  pedicles 
rather  than  by  broad  bases.  Mixed  forms  are  also  found,  §  in  which  the 
parent  cyst-wall  bears,  at  one  part,  oval  and  spherical  membranous 
cysts,  developed  beneath  its  lining  membrane,  which  they  raise  in  low 
convex  projections  into  its  cavity  ;and  at  another  part,  groups  of  small 
leaf-like,  narrowly  pedunculated,  and  pendulous  cysts.  And,  again, 
the  same  prolific  power  which  is  shown  in  these  endogenous  converging 
cysts,  is  often,  in  the  same  specimens,  shown  in  exogenous  growths ; 
similar  cysts,  singly  or  in  clusters,  projecting  from  the  exterior  walls  of 
the  parent.  II 

But  a  lecture  would  not  suffice  to  describe,  even  briefly,  the  variety 
of  forms  into  which  these  ovarian  proliferous  cysts  may  deviate. 
Whether  we  regard  their  walls,  the  arrangement  and  shape  of  the  endo- 
genous cysts,  their  seats  and  modes  of  origin,  their  various  contents, 
and  the  yet  greater  differences  engendered  by  disease,  they  are  so  mul- 


*  Series  xxxi,  18. 

f  Fig.  47,  part  of  the  wall  of  a  proliferous  ovarian  cyst  described  above  :  natural  size, 
j  Nos.  165  A,  and  165  b.  §  No.  2621. 

II  No.  2622  in  the  College  Museum  presents  an  instance  of  the  endogenous  and  exogenous 
modes  of  growth  in  the  same  specimen. 


CYSTIC    DISEASE    OF    THE     CHORION. 


377 


tiform  that  even  imagination  could  hardly  pass  the  boundaries  of  their 
diversity.  It  must  suffice  to  refer  to  Dr.  Hodgkin's  works  for  an 
elaborate  account  of  the  structure  and  arrangement  of  the  cysts  :  and 
to  the  essays  of  Dr.  Tilt*  for  descriptions  of  their  contents. 

The  foregoing  account  of  the  structure  of  these  cyst-bearing  cysts  in 
the  ovaries  is  derived  entirely  from  naked-eye  observations.  Respect- 
ing the  mode  of  generation  of  the  endogenous  cysts,  it  could  only  be 
supposed  that  they  are  derived  from  cell-germs  developed  in  the  parent 
cyst-walls,  and  thence,  as  they  grow  into  secondary  cysts,  projecting 
into  the  parent  cavity ;  or,  disparting  the  midlayers  of  the  walls,  and 
remaining  quite  inclos- 
ed between  them;  or,  ^'  '^ 
more  rarely,  growing 
outwards,  and  project- 
ing into  the  cavity  of 
the  peritoneum. 

But  a  more  complete 
illustration  of  the  origin 
of  such  secondary  cysts, 
and  a  good  confirmation 
of  what  I  have  been  de- 
scribing, may  be  drawn 
from  Dr.  Mettenhei- 
mer's  investigations  on 
the  microscopic  struc- 
ture of  the  cystic  dis- 
ease of  the  chorion,  f 
Some  of  his  illustrations 
are  copied  in  Fig.  48. 

The  general  charac- 
ters of  this  disease,  con- 
stituting the  hydatid 
mole,  are  well  known. 
A  part,  or  even  the 
whole  of  the  chorion  is       c  d  e 

*  Lancet,  1849. 

f  Muller's  Archiv,  1850,  H.  v,  p.  417.  His  account,  though  different  in  interpretation, 
is  consistent,  as  to  facts,  with  one  by  Gierse  and  H,  Meckel,  in  the  Verhandl.  der  Gesellsch. 
fiir  Geburtshulfe  in  Berlin,  1847.  The  interpretation  advanced  by  Gierse  is  indeed  quite 
opposed  to  Mettenheimer's  view  that  the  cyst  formation  is  due  to  enlargement  of  the  cells 
of  the  villi,  for  the  former  regards  the  cysts  as  produced  by  a  simple  distension  of  the  villi, 
through  an  accumulation  of  fluid  in  the  loose  tissue  in  their  interior.  But  in  advancing  this 
interpretation,  it  appears  not  to  have  been  sufficiently  recognized,  that  cells  are  found,  not 
only  on  the  surface  of  the  villi,  but  also  imbedded  in  their  substance,  and  that  by  the  disten- 
sion of  these  latter,  the  cyst  formation  is  produced.  The  opinion  of  Gierse  has  been  adopted 
by  Dr.  Graily  Hewitt,  in  a  paper  in  the  Trans.  Obst.  Soc,  Lond.,  vol.  i,  1859. 

J  Fig,  48,  cystic  disease  of  the  chorion,  as  described  above:  A  and  B,  natural  size;  C,  D, 
E,  magnified  250  times. 

25 


378  CYSTIC    DISEASE     OF    THE     CHORION. 

covered  with  pellucid  vesicles  with  limpid  contents,  borne  on  long, 
slender,  and  often  branching  pedicles  (a).  The  cysts  are  usually  oval 
or  pyriform ;  their  walls  are  clear,  or  have  minute  opaque  dots  (b)  ;  they 
may  be  simple,  or  may  bear  others  projecting  from  their  walls. 

Dr.  Mettenheimer  has  found  that  the  minute  dots  besetting  these 
cysts  are  villous  processes,  exactly  resembling  those  of  the  natural 
chorion,  and  growing  from  the  walls  of  the  cysts,  either  outwardly  or 
into  their  cavities.  In  these  villi  he  traced  the  development  of  cysts. 
In  their  natural  state  the  villi  may  be  described  as  filiform  or  clavate 
processes,  often  branching  and  bearing  bud-like  projections,  and  com- 
posed of  dimly-granular  substance,  in  which  are  imbedded  minute  nucle- 
ated cells  (c).  In  this  cystic  disease,  vesicular  bodies  may  be  seen  (as 
in  D  and  e)  scattered  among  the  cells  in  the  villi,  which  bodies  are  dis- 
tinguished from  the  cells  by  their  pellucidity,  their  larger  size,  and, 
when  largest,  by  double  contours ;  but,  from  the  cells  to  these,  every 
gradation  may  be  so  traced  as  to  leave  scarcely  a  doubt  that  the  vesicles 
are  derived  from  cells  deviating  from  their  normal  characters.  Thus, 
in  some  of  the  cells,  the  contents  are  seen  lighter  and  less  granular ; 
in  some  they  have  entirely  disappeared,  without  increase  of  size ;  and 
then,  when  their  contents  are  thus  become  uniformly  pellucid,  and  they 
have  acquired  the  character  of  vesicles,  the  cells  appear  to  grow,  while 
their  walls  become  stronger,  and  they  acquire  such  a  size  that  they  are 
recognized  as  very  small  cysts,  similar,  in  all  but  their  size,  to  those 
which  are  visible  to  the  naked  eye. 

Now,  though  this  method  of  formation  of  cysts  has  been  traced  by 
Mettenheimer  only  in  the  villi  which  grow  on  the  cysts  themselves,  and 
therefore,  so  to  speak,  only  in  the  production  of  cysts  of  the  second  and 
later  generations,  yet  there  can  be  little  doubt  that  the  first  cysts  in 
the  diseased  choi'ion  are  formed  in  its  own  villi  after  the  same  manner. 
Eor  the  villi  which  are  borne  on  the  cysts,  and  which  to  the  naked  eye 
appear  like  little  dots,  are,  in  all  essential  characters,  like  those  natural 
to  the  chorion ;  and  the  cysts  of  all  generations  are  equally  like.  The 
whole  process  may,  therefore,  be  probably  thus  described:  Certain  of 
the  cells  in  the  proper  villi  of  the  chorion,  deviating  from  their  cell- 
form,  and  increasing  disproportionally  in  size,  form  cysts,  which  remain 
connected  by  the  gradually  elongated  and  hypertrophied  tissue  of  the 
villi.  "  On  the  outer  surface  of  the  new-formed  cysts,  each  of  which 
would,  as  it  were,  repeat  the  chorion,  and  surpass  its  powers,  a  new 
vegetation  of  villi  sprouts  out,  of  the  same  structure  as  the  proper  villi 
of  the  chorion.  In  these  begins  again  a  similar  development  of  cysts ; 
and  so  on  ad  infinitum."  Each  cyst,  as  it  enlarges,  seems  to  lead  to 
the  wasting  of  the  cells  around  it ;  and  then,  moving  away  from  the 
villus  in  which  it  was  formed,  it  draws  out  the  base  of  the  villus,  which 
strengthens  itself,  and  forms  the  pedicle  on  which  the  cyst  remains 
suspended. 

Such  is  the  account  of  the  minute  structure  and  formation  of  the 


PROLIFEROUS    CYSTS    WITH    VASCULAR     GROWTHS.         379 

cystic  disease  of  the  chorion;  and  perhaps  no  instance  could  afford  a 
better  confirmation  of  the  production  of  cysts  by  the  enormous  growth 
of  elementary  cells,  or  a  better  type  of  the  capacity  of  cysts  thus  formed 
to  produce  structures  resembling  those  in  the  abnormities  of  which  them- 
selves originated.  A  similar  capacity  is  among  the  characters  of  all 
the  cysts  of  which  I  shall  next  have  to  speak. 

2.  I  pass  now  to  the  consideration  of  the  cysts  that  are  proliferous 
with  vascular  growths  from  their  internal  surfaces.* 

The  first  group  of  them  may  include  those  that  bear  glandular 
growths — the  "glandular  proliferous  cysts,"  as  we  may  call  them,  be- 
cause the  minute  structure  of  the  substance  growing  into  them  is,  in  its 
perfect  state,  exactly  comparable  with  that  of  a  secreting  or  vascular 
gland. 

Such  cysts  form  part  of  the  group  to  which  the  name  of  "  sero-cystic 
sarcoma,"  was  given  by  Sir  B.  C.  Brodie,  who  first  clearly  distinguished 
them.f  They  are  also  part  of  those  which  furnished  to  Dr.  Hodgkin 
the  chief  ground  for  his  well-known  theory  of  the  formation  of  solid 
tumors — a  theory  which,  in  regard  to  at  least  these  growths,  has  good 
foundation. 

The  chief  seats  of  the  formation  of  glandular  proliferous  cysts  are 
the  mammary  and  thyroid  glands.  Their  history  in  the  thyroid,  in  which 
their  formation  scarcely  passes  the  bounds  of  health,  is  amply  illus- 
trated in  the  often-cited  works  of  Frerichs  and  Rokitansky,  to  which, 
as  well  as  to  the  essay  by  Mr.  Simon|  on  the  natural  structure  of  the 
gland,  I  must,  for  brevity's  sake,  refer. 

A  series  of  preparations,!  such  as  are  represented  in  Figs.  49,  50, 

*  It  may  be  well  to  refer  to  the  fact  that  abnormal  growths  upon  natural  free  surfaces 
commonly  affect  the  same  forms,  as  will  be  described  in  the  following  account  of  the  vascu- 
lar growths  in  cysts.  The  chief  forms  are  three:  namely,  1st,  groups  of  slender,  small,  and 
pedunculated  bodies;  2d,  large  round  pendulous  masses;  3d,  nearly  level,  slightly  elevated 
layers,  such  as  granulations.  Now  groups  of  pedunculated  leaf-like  processes  occur  on 
natural  free  surfaces;  in  the  growths  that  are  so  frequent  in  chronic  rheumatic  diseases  of 
joints,  from  some  of  which  Miiller  draws  his  account  of  lipoma  arboreseens;  in  certain 
warty  cancerous  growths  on  the  skin,  which  appear  like  cancerous  overgrowths  of  the  pa- 
pillae; and  in  similar  growths  in  the  larynx  about  the  vocal  cords.  Of  the  larger,  round, 
pedunculated  masses,  growing  on  natural  free  surfaces,  instances  exist  in  the  medullary  can- 
cers of  the  urinary  bladder,  the  polypi  of  the  intestines  and  stomach,  the  pendulous  out- 
growths of  the  skin.  And  of  the  flatter,  and  more  nearly  level  layers,  the  condylomatous 
outgrowths  of  skin,  the  epithelial  cancers  of  the  stomach  and  intestines,  and  the  cheloid 
growths,  often  afford  examples.  There  is  in  all  these  resemblances  a  good  illustration  of  the 
tendency  of  the  growths  in  cysts  to  imitate  those  on  natural  parts. 

f  The  disease  is  admirably  illustrated  by  the  specimens  in  the  Museum  of  the  College, 
and  in  those  of  St.  George's,  Guy's  and  St.  Bartholomew's  Hospitals.  A  well-marked  case 
in  the  breast,  by  Busch,  in  Chirurgische  Beobachtungen,  Berlin,  1854,  8vo.  p.  85,  showing 
much  of  the  growth  as  abnormal  gland-structures,  and  suggesting  that  the  apparently  intra- 
cystic  growths  are  projections  from  without.  Also  cases  by  Maur.  Collis,  in  Dublin  Quarty. 
Jour.  Nov.  1860. 

J  Philosophical  Transactions,  1844,  part  ii. 

§  Such  as  those  in  the  College  Museum,  Nos.  168  to  172,  &c. 


380 


PROLIFEROUS     MAMMARY    CYSTS. 


51,  may  clearly  illustrate  the  corresponding  process  in  the  mammary 
gland  ;*  but  here  the  conditions  are  far  more  remote  from  the  normal 
type.     If  we  may  believe  that  a  series  of  specimens  may  be  read  as  the 

continuous  history  of  one  case, 
Fig.  49.  J  because  they  seem  to  present  suc- 

cessive phases  of  the  same  disease, 
then,  we  may  suppose,  first  the 
existence  of  a  cyst  (Fig.  49),  or 
of  a  collection  of  cysts  (Fig.  51), 
in  the  mammary  gland.  Such 
cysts  may  be  formed  by  the  dila- 
tation of  parts  of  ducts  ;  but  much 
more  commonly,  the  cysts  that 
bear  vascular  growths  are  derived 
through  transformation  and  enor- 
mous growth  of  some  elementary 
structure  of  the  gland. f  So  far 
as  I  know,  there  is  nothing  pecu- 
liar in  the  structure  of  the  mam- 
,  mary  cysts  that  may  be  prolifer- 
ous. They  are  usually  ovoid  or  spherical,  unless  changed  by  mutual 
compression,  as  in  Fig.  51 ;  they  usually  appear  formed  of  thin  white 
fibrous  tissue,  with  or  without  elastic  fibres  ;  they  have  abundant  blood- 
vessels, and  are  closely  adherent  to  the  surrounding  parts :  their  walls 
are  peculiarly  apt  in  disease  to  become  oedematous,  succulent,  and 
almost  gelatinous.  They  may  grow  to  an  enormous  size.  A  specimen 
is  in  the  Museum  of  St.  George's  Hospital,  in  which  a  cyst,  that  would 
contain  more  than  two  pints  of  fluid,  has  some  lowly  lobed  growths  from 
one  portion  of  its  inner  surface ;  one  in  the  College  Museum,  removed 
by  Mr.  Listen,  weighed  twelve  pounds ;  and  Dr.  Warren  relates  a  case 
in  which  he  removed  a  tumor  of  this  kind  of  thirteen  pounds  weight. 
The  cysts  may  contain  any  of  the  varieties  of  serous  or  bloody  fluid, 
clear  or  turbid,  that  I  described  in  the  last  lecture. 

Now,  from  some  part  of  the  inner  surface  of  such  a  cyst,  a  vascular 
growth  may  spring  (Fig.  49) ;  and,  as  this  gradually  increases  at  a  rate 
beyond  that  of  the  increase  of  the  cyst,  it  fills  more  and  more  of  the 
cavity.  At  length  the  growth  wholly  excludes  the  fluid  contents  of  the 
cyst,  and  its  surfaces  come  in  contact  with  the  remainder  of  the  cyst- 
walls  (Figs.  50,  51).  The  growth  may  now  coalesce  with  the  walls  of 
the  cyst,  and  form  one  solid  tumor,  inclosed  in  and  connected  with  them, 

*  All  the  cases  recorded  have  occurred  in  the  female  breast,  except  two :  one  by  Mr. 
Arnott;  Medical  Gazette,  xxii,  378  :  and  one  by  Miiller ;  On  Cancer,  p.  180. 

f  On  the  difference  between  the  solid  contents  of  dilated  ducts,  and  those  of  the  proper 
or  autogenous  cysts,  see  Mr.  Birkett"s  account  in  his  Essay  on  the  Diseases  of  the  Breast. 

J  Fig.  49,  a  cyst  in  a  mammary  gland,  to  part  of  the  inner  surface  of  which  a  vascular 
growth  is  attached.  Below  it  a  smaller  cyst  is  nearly  filled  with  a  similar  growth.  Mus. 
St.  Bartholomew's  :  three-fourths  of  the  natural  size. 


PROLIFEROUS    MAMMARY    CYSTS. 


381 


just  as  ordinary  solid  tumors  are  invested  and  connected  with  their  con- 
nective tissue  capsules. 

Or  growing  yet  further  ^^' 

and  more  rapidly,  the 
growth,  ■  hitherto  intra- 
cystic,  may  protrude 
through  its  cyst-walls 
and  the  superjacent  in- 
teguments :  protruding 
through  them  as  a  her- 
nia of  the  brain  does 
through  the  skull,  grow- 
ing exuberantly  over  the 
adjacent  skin  (Fig.  51), 
and,  likp  such  a  hernia, 
reproduced  when  cut 
away. 

The  time  in  which  these  changes  may  be  accomplished  is  extremely 
various.  Usually  the  increase  of  the  intra-cystic  growth  appears  to 
be  painless,  and  it  may  be  very  slow:  ten  years  or  more  may  pass  with 
little  change;  but  the  increase  is  generally  faster,  and  it  often  shows 
an  accelerating  rate;  so  that,  late  in  the  disease,  the  progress  is  ex- 
tremely quick,  even  quicker  than 
that  of  most  cancerous  growths.  Fig.  Slf. 

The  characters  of  the  intra- 
cystic  mammary  growths  are 
various,  not  only  according  to 
our  observations  of  them  at  dif- 
ferent periods  of  their  existence, 
but,  apparently,  even  from  their 
very  origin.  In  looking  through 
a  large  series  of  them  while  they 
are  still  in  early  periods  of  their 
development,  we  may  reduce 
them  to  these  chief  forms ;  name- 
ly, low,  broad-based,  convex  lay- 
ers, like  coarse  granulations ; 
spheroidal,  lobed,  and  nodulated 
masses,  cauliflower-like,  attached 
by  narrower  bases  (Fig.  49); 
masses  or  clusters  of  peduncu- 
lated leaf-like  processes,  slender, 

*  Fig.  50,  a  cyst  in  the  mammary  gland  filled  with  a  vascular  growth  bearing  clusters 
of  pedunculated  processes.     Mus.  Coll.  Surg.     Natural  size. 

t  Fig.  51.  collection  of  cysts  filled  with  glandular  growths  in  and  protruding  from  the 
mammary  gland :  described  on  the  next  page.     Half  the  natural  size. 


382  PROLIFEROUS    MAMMARY    CYSTS. 

single,  or  variously  branched,  and  interlaced  in  all  possible  forms 
(Fig.  50) ;  masses  of  firmer  and  much  paler  substance,  appearing  as  if 
formed  of  close-packed  lobes,  or  fimbriated  processes,  or  involuted  layers 
(Fig.  51). 

In  apparent  structure,  also,  the  varieties  of  these  growths  are  scarcely 
less  numerous.  Some  of  them  are  opaque,  yellow,  and  soft,  yet  elastic, 
and  rather  tough,  so  as  to  be  separable  in  laminae  like  a  fibrine  clot; 
others  are  more  vascular,  succulent,  and  spongy,  like  granulations ; 
others  are  like  layers  and  masses,  or  heaped  up  layers,  of  gelatine,  not 
firmer  than  size,  or  even  like  vitreous  humor,  yielding  a  tenacious  syno- 
via-like fluid :  others  are  firm,  compact,  nearly  pure  white,  imitating 
the  mammary  gland,  but  not  succulent. 

To  these  varieties  of  appearance  we  might  add  yet  more,  due  either  to 
diverse  shades  of  yellow,  pink,  gray,  or  purple;  or  to  the  various  clus- 
tering and  incomplete  fulness  of  the  cysts ;  or  to  the  increasing  firm- 
ness of  the  growths,  and  their  fusion  with  the  cell-walls;  or  to  the 
development  of  new  barren  or  proliferous  cysts  in  the  solid  growths 
that  now  fill  the  cysts  of  a  former  generation  ;  or  to  various  changes  of 
decay  or  disease  ensuing  in  either  the  cyst-walls  or  their  contents. 

It  would  be  too  tedious  to  describe  all  these  varieties,  especially  while 
we  do  not  yet  know  whether,  or  in  what  degree,  these  forms  are  related 
to  one  another,  or  to  any  one  typical  condition  of  the  intra-cystic 
growths. 

Respecting  their  minute  structure,  we  have  good  guidance  in  the 
probability,  which  will  be  supported  in  the  twenty-eighth  lecture,  that 
the  proper  mammary  glandular  tumors — the  chronic  mammary  tumors 
of  Sir  A.  Cooper — have  their  origin  in  intra-cystic  growths,  transformed 
into  solid  tumors  in  the  manner  just  described.  The  mammary  glan- 
dular tumors  are  composed  of  minute  structures  closely  imitating  those 
of  the  gland  itself.  They  present  microscopic  lobes,  and  fine  tubules, 
lined  or  filled  with  nuclei  and  nucleated  cells,  like  those  of  secreting 
organs ;  these,  inclosed  within  pellucid  membrane,  form  a  pseudo-glan- 
dular substance,  such  as,  we  might  suppose,  needs  only  a  main  duct  to 
enable  it  to  discharge  the  ofiice  of  a  mammary  gland.  In  the  like 
manner  and  degree,  in  some  specimens  in  which  the  cysts  and  their 
contained  growths  are  still  easily  separable,  we  can  discern  in  the 
growths  a  likeness  to  the  mammary  gland  itself  in  their  minute  struc- 
ture. 

These  facts  have  been  observed  especially  by  Mr.  Birkett,*  and  were 
very  well  marked  in  a  case  which  I  was  able  to  examine,  and  of  which 
Fig.  51  represents  a  section.  It  was  a  very  large  protruding  tumor  of 
the  breast,  removed  by  Mr.  Lawrence  from  a  lady  55  years  old.  It 
had  been  observed  for  thirty  years,  remaining  like  a  small  knot  for 

*  Especially  in  his  Essay  on  Diseases  of  the  Breast,  and  in  the  Guy's  Hospital  Reports, 
1855. 


PROLIFEEOUS     MAMMAEY    CYSTS.  383 

twenty-six  years,  and  then  slowly  increasing,  till,  at  the  end  of  five 
years,  a  red  fungous  mass  protruded  from  the  breast,  bled  freely  some- 
times, and  discharged  profusely.  This,  too,  increased  quickly,  and  was 
painful.     The  whole  breast  was  removed,  and  the  patient  recovered. 

The  tumor  (Fig.  51)  measured  nearly  seven  inches  by  five.  The  part 
which  did  not  protrude  beyond  the  level  of  the  skin  was  imbedded  in 
the  substance  of  the  gland.  It  consisted  of  numerous  lobes  of  various 
sizes  and  shapes,  and  variously  divided  into  smaller  lobes;  all  being 
evidently  formed  of  distinct  cysts  closely  packed  and  compressed  toge- 
ther. Most  of  these  cysts  were  filled  with  intra-cystic  growths ;  yet 
in  many  Of  them  it  was  easy  to  pass  a  probe  between  their  walls  and 
the  surfaces  of  their  contained  growths,  which  were  fixed  to  only  one 
part  of  the  cyst-walls.  In  the  protruding  part,  of  which  the  overhang- 
ing outer  border  is  shown  in  the  sketch  (Fig.  51),  the  same  general  plan 
of  structure  could  be  discerned,  but  less  distinctly. 

Among  the  solid  growths  that  filled  the  cysts,  some  showed  clavate, 
close-packed  lobes ;  some  were  nearly  simple  ;  nearly  all  were  pale, 
white,  grayish  or  yellowish,  and  smooth  and  shining  ;  a  few  were  spotted 
with  yellow,  from  degeneration  of  their  tissue.  Repeated  examinations 
showed  that  all  these  consisted  essentially  of  a  tissue  imitating  that  of 
a  gland,  and  such  as  will  be  described  in  the  twenty-eighth  lecture. 
The  edges  and  surfaces  of  the  examined  portions  were  minutely  lobed 
or  acinous,  like  terminations  of  gland-tubes.  These  were  inclosed  by 
well-defined,  pellucid  membrane :  and  their  cavities  were  full  of  nuclei 
and  nucleated  cells,  like  mammary  gland-cells,  with  some  granular 
matter.  Except  in  that  these  acini  led  to  no  distinct  ducts,  but  seemed 
confusedly  heaped  together,  the  imitation  of  gland-structure  was  com- 
plete. 

Now,  the  glandular  nature  of  these  growths  in  the  best-marked  cases 
of  proliferous  mammary  cysts,  and  the  probably  constant  relation  of  the 
mammary  glandular  tumors  to  them,  as  well  as  the  analogy  of  the  intra- 
cystic  thyroid  growths,  may  seem  to  make  it  probable  that,  in  all  cases, 
the  growths  within  the  mammary  cysts  are  of  essentially  the  same  glan- 
dular nature,  and  that  their  various  appearances  are  due  to  their  being 
in  rudimental,  or  degenerate,  or  diseased  states.  But  we  cannot  be 
sure  of  this.  In  three  cases,  in  which  I  have  minutely  examined  soft 
intra-cystic  grow^ths,  I  could  not  recognize  a  glandular  structure.  In 
all,  I  found  a  basis-substance,  which  was  pellucid,  soft,  and  in  one  case 
difiluent ;  it  had  little  or  no  appearance  of  fibrous  structure,  and  no  dis- 
tinct fibres,  but,  rather,  presented  the  uniformity  as  well  as  the  consis- 
tence of  soft  gelatine.  In  it,  as  in  a  blastema,  were  imbedded  nuclei 
and  cells,  which  chiefly  presented  the  forms  of  developing  connective 
tissue,  like  those  in  granulations,  or  of  inflammatory  Ij'-mph  :  or  their 
forms  might  be  explained,  I  think,  by  the  disorderly  conditions  of  their 
production  and  development.     Nearly  similar,  and  equally  indecisive 


384  VARIOUS    PROLIFI?ROUS     CYSTS. 

results  appear  from  an  accurate  observation  of  such  a  growth  by  Dr. 
Mettenheimer,*  and  from  two  cases  related  by  Bruch.f 

Perhaps  we  may  conclude  that,  in  these  specimens,  the  intra-cystic 
growths  were  in  a  rudimental,  or  in  a  morbid  state ;  that  the  general 
destiny  of  such  growths  is  towards  a  glandular  structure,  but  in  these 
and  the  like  instances  they  fell  short  of  it,  or  swerved  from  the  right 
course.  But  I  would  rather  not  form  any  conclusion  at  present.  These 
are  just  the  cases  of  which,  as  yet,  the  interpretation  is  scarcely  possi- 
ble, while  we  are  ignorant  of  the  changes  that  may  ensue  during  de- 
velopment, degeneration,  and  disease. 

I  have  said  that  the  mammary  and  thyroid  glands  might  be  regarded 
as  the  elected  seats  for  cysts  having  glandular  growths  ;  but  they  are 
sometimes  met  with  in  other  parts,  as  in  the  prostate,  and,  I  believe, 
also  in  the  lip.  In  the  Museum  at  St.  George's  Hospital  is  a  tumor 
removed  from  a  man's  upper  lip,  in  which  it  had  been  growing,  without 
pain,  for  8J  years.  One-half  of  it  is  a  cyst  that  was  filled  with  a  thin 
flaky  fluid,  and  was  thought  to  be  a  dilated  labial  gland-duct ;  the  other 
half  is  a  solid  tumor,  just  like  a  glandular  tumor  of  the  lip  which  I  shall 
describe  in  a  future  lecture.  I  have  lately  seen  another  case  with 
nearly  the  same  characters  :  and  the  combination  of  a  barren  cyst  with 
a  proliferous  one,  which  they  seem  to  illustrate,  is  not  rare  in  the  mam- 
mary gland.  In  the  same  Museum  is  a  cyst,  with  a  broad  vascular 
growth,  like  granulations,  from  its  walls,  which  was  taken  from  a  girl's 
labium  by  Mr.  Cutler.  It  has  a  small  external  opening,  suggesting 
that  it  may  have  had  its  origin  in  a  cystic  mucous  or  sebaceous  gland.| 
In  the  College  Museum,  No.  167,  is  a  thick-walled  cyst,  from  the  cheek 
of  an  old  woman,  which  contains  two  large,  lobed,  and  pedunculated 
masses,  so  like  some  of  those  found  in  the  mammary  cysts  that  we  can 
hardly  doubt  their  glandular  nature. 

All  these  specimens,  however,  need  more  minute  examination ;  at 
present  they  only  make  it  probable  that  any  cyst  originating  in  or  near 
a  secreting  gland  may  be  the  parent,  or  the  habitation,  of  an  endoge- 
nous glandular  growth. 

To  this  account  of  glanduliferous  cysts  it  must  be  added,  that  their 
characters  may  be  closely  imitated  by  cysts  formed  in  parts  altogether 
unconnected  with  secreting  glands.  It  is  not,  indeed,  probable  that 
the  contained  growths  in  such  cysts  are  glandular ;  yet  they  present 
characters  like  the  softer  growths  that  are  found  in  the  mammary  cysts. 

*  Mailer's  Archiv,  1850,  p.  207. 

f  Die  Diagnose  der  bosartigen  Geschwulste,  pp.  1S5,  19]. 

J  See  also  an  account  of  a  specinnen  in  the  same  Museum,  by  Mr.  Hawkins  :  Medical  Ga- 
zette, xxi,  p.  9.51;  and  Proc.  of  Pathol.  Soc.  ii,  p.  340.  I  suppose  there  is  some  relation 
between  these  and  the  subcutaneous  warts  and  condylomata  described  by  Hauck  and 
Kramer  ;  but  I  have  not  seen  what  they  refer  to.      (See  Simon :  Hautkrankheiten,  p.  225.) 


VAKIOUS     PROLIFEROUS     CYSTS.  385 

I  found  one  of  these  proliferous  cysts  beneath  the  gracilis  and  ad- 
ductor longus  muscles  of  a  woman  twenty-five  years  old.  It  was  a 
large  spheroidal  mass,  which  felt  as  if  held  down  tightly  on  the  front 
of  the  pelvis,  and  had  pushed  the  femoral  vessels  a  little  outwards.  It 
lay  too  deep  to  form  a  clear  diagnosis  of  its  nature  ;  it  was  assigned  to 
no  distinct  cause ;  it  had  been  noticed  for  only  seven  months,  but  when 
first  seen  was  "  as  large  as  a  tea-cup."  I  removed  it  without  much 
diflBculty  ;  for  it  Avas  not  closely  adherent  to  the  parts,  except  to  a  small 
portion  of  the  front  of  the  pubes,  where  it  rested  on  the  adductor  bre- 
vis.     The  patient  has  since  remained  well  for  more  than  three  years. 

The  tumor  was  spheroidal,  about  four  inches  in  diameter,  and  con- 
sisted chiefly  of  cysts,  from  two  of  which  six  or  eight  ounces  of  turbid 
serous  fluid  escaped  when  they  were  cut  across.  One  of  these  cysts  was 
thickly  lined  with  pale,  brownish,  fibrinous  substance,  like  that  which 
one  finds  in  old  hsematoceles ;  and  this  appeared  as  fibrine  on  minute 
examination.  Another  was  nearly  filled  with  a  ruddy  mass,  in  most 
parts  soft  and  succulent,  like  blood-stained  gelatine.  Much  of  this 
mass  was  also  like  fibrine-clot,  with  abundant  corpuscles  ;  but  the 
layers  of  it  next  the  cyst-walls  were  firmer  than  the  central  parts,  and 
contained  all  the  forms  that  one  finds  in  common  granulations  develop- 
ing into  connective  tissue.  The  microscopic  likeness  to  granulations 
was,  in  these  parts,  exact.  The  rest  of  the  tumor,  including  some  large 
portions  between  the  cysts,  consisted  of  connective  tissue  more  or  less 
perfectly  developed.* 

A  similar  tumor,  was  removed  by  Mr.  Lawrence  from  the  exactly  cor- 
responding part  of  a  woman  50  years  old,  in  whom  it  had  grown  slowly, 
and  without  pain,  for  nine  or  ten  years.  It  gave  the  sensation  of  a 
firm  fatty  tumor,  as  large  as  an  egg,  but  when  removed  was  found  to 
be  a  bilocular  cyst.  Each  cavity  contained,  together  with  serous  fluid, 
a  soft,  reddish,  gelatinous-looking  mass,  like  a  polypus  in  one,  and  solid 
and  folded  in  the  other.  The  cyst-walls  were  tough,  pure  white,  formed 
of  connective  tissue,  and  polished  on  their  inner  surface.  The  in- 
tra-cystic  growths  consisted  of  a  structureless  or  dimly  granular  or 
fibrillating  blastema,  with  abundant  oily  molecules,  granule-cells,  and 
corpuscles,  like  nuclei,  imbedded  in  it. 

And  to  these  two  instances,  since  the  disease  seems  very  rare,  I  may 
add  a  third.  A  girl  twenty-three  years  old,  under  the  care  of  Mr. 
Lawrence,  had  a  pyriform  pendulous  tumor  in  her  neck,  about  2J  inches 
long.  Its  surface  was  ulcerated,  livid,  and  painful,  and  bled  occasion- 
ally. Its  history  was  doubtful ;  but  it  had  existed  for  at  least  a  year. 
On  removal,  it  appeared  to  have  grown  in  the  subcutaneous  tissue,  and 
to  be  composed  of  a  collection  of  cysts,  closely  and  irregularly  packed, 
and,  for  the  most  part,  filled  with  lobed,  soft,  cauliflower-like  growths 
from  parts  of  their  walls.     It  closely  resembled,  in  its  general  aspect, 

*  The  tuinor  is  in  the  Museum  of  St.  Bartholomew's  Hospital. 


386  VARIOUS    PROLIFEROUS    CYSTS. 

the  collections  of  proliferous  cysts,  with  soft  intra-cystic  growths,  in  the 
mammary  gland.  In  microscopic  structure  the  intra-cystic  growths  ap- 
peared composed  entirely  of  corpuscles,  like  those  of  lymph  or  granu- 
lations :  but  my  record  of  the  examination,  made  several  years  ago,  is 
too  incomplete  for  a  clear  account  of  them. 

I  believe  that  all  the  cysts  that  I  spoke  of,  before  these  that  contain 
vascular  growths,  may  be  regarded  as  completely  void  of  the  characters 
of  malignant  disease;  at  least,  I  have  met  with  no  evidence  contrary  to 
this  statement,  except  in  certain  cases  of  proliferous  ovarian  cysts,  to 
which  I  shall  presently  refer.  And,  in  general,  the  reputation  of  in- 
nocency  is  deserved  by  the  glanduliferous  cysts  also.  Yet  there  are 
cases  which  show  that  such  tumors  may  have  an  exceeding  tendency  to 
recur  after  removal. 

A  healthy  robust  woman,  37  years  old,  was  under  Mr.  Lawrence's 
care  with  a  very  large  protruding  tumor  in  her  right  breast.  This  had 
been  slowly  increasing  for  ten  years,  but,  till  lately,  had  given  little 
uneasiness,  except  by  its  bulk,  and  had  not  hindered  her  nursing.  Mr. 
Lawrence  removed  the  greater  part  of  the  breast  and  the  tumor  in  1844. 
It  weighed  7J  pounds,  and  was  a  well-marked  example  of  that  form  of 
"  sero-cystic  sarcoma,"  in  which  the  cyst-walls,  as  if  altered  by  inflam- 
mation, or  imperfectly  formed,  are  soft,  succulent,  and  glistening,  with 
solid  growths  of  similar  substance,  lobed  and  fissured.  Many  cysts  in 
it  still  contained  serous  fluid.  Its  appearance  when  recent,  and  even 
now  as  preserved,*  leaves  no  room  for  doubt  as  to  its  nature. 

The  patient  remained  well  for  fifteen  months  ;  then  a  tumor  began 
to  grow  under  the  scar,  and  quickly  increased.  After  nine  months' 
growth  Mr.  Lawrence  removed  this  also,  with  all  the  surrounding  tis- 
sues. It  was  a  pale,  pinkish,  and  yellowish  mass,  like  soft  size  or  jelly. 
It  was  lobed  and  folded,  and  included  some  irregular  spaces,  containing 
a  fluid  like  mucus  or  half  melted  jelly.  It  was  like  the  solid  parts  of  the 
tumor  last  removed,  and  consisted  of  a  pellucid  dimly  fibrillated  blas- 
tema or  basis-substance,  in  which  were  imbedded  nuclei  and  abundant 
granule-cells,  of  various  forms.  The  sketches  and  account  of  these, 
which  I  drew  at  the  time,  make  me  still  sure  that  they  had  none  of  the 
characters  of  cancer-cells,  but  were  like  nuclei  of  ordinary  form,  or 
elongated,  many  of  which  were  changed  by  fatty  or  granular  degenera- 
tion. 

After  this  second  operation,  the  patient  remained  well  for  seven 
months,  and  fully  regained  her  stout  robust  appearance.  But  now  a 
third  tumor  appeared  ;  a  fourth  soon  after  ;  and  both  grew  rapidly,  till, 
after  two  months,  Mr.  Lawrence  removed  them,  and  all  the  parts  bound- 
ing them.  They  were,  in  every  respect,  exactly  like  those  removed  in 
the  last  operation,  and  near  them  lay  another  not  discerned  before  the 
removal.  Erysipelas  following  this  operation  proved  fatal,  and  no  post- 
mortem examination  could  be  obtained. 

*  In  the  Museum  of  St.  Bartholomew's,  Ser.  xxxiv,  Nos.  19  and  20. 


RECURRING    PROLIFEROUS    CYSTS.  387 

Now  in  the  first  of  these  operations  some  portion  of  the  mammary  gland 
was  left.  It  is  possible  that  some  cysts  already  existed  in  this  portion, 
and  were  subsequently  developed  into  the  second  tumor,  which,  there- 
fore, might  not  deserve  to  be  called  a  recurring  tumor,  although,  indeed, 
it  appeared  under  the  scar  of  the  former  operation,  and  not  in  the 
place  where  gland- substance  was  left.  But,  after  the  second  operation, 
there  is  little  probability  that  any  gland  remained ;  and  we  may,  with 
as  little  doubt,  regard  the  third  tumor  as  an  instance  of  recurrence 
or  repetition ;  i.  e.  of  reappearance  of  the  disease  in  an  entirely  new 
growth. 

Sir  B.  C.  Brodie*  has  related  two  cases  of  single  recurrence  of  tumors 
very  closely  resembling  that  just  now  described;  and  the  liability  to 
recurrence  which  Mr.  Lawrence's  case  presented  is  surpassed  by  one 
recorded  by  M.  Lesauvages,t  whose  description  of  the  tumors  he  re- 
moved accords  so  closely  with  what  was  observed  in  the  foregoing  case, 
that  I  can  have  very  little  doubt  they  were  of  the  same  nature.  The 
patient  was  63  years  old.  The  first  tumor  of  the  breast,  which  was  of 
great  size,  was  removed  in  February,  1832  ;  a  se'bond  appeared,  and 
was  removed  before  the  healing  of  the  first  wound  ;  a  third  in  May  ;  a 
fourth  in  September  of  the  same  year  ;  a  fifth  sprang  up,  and  was  re- 
moved in  February,  1833 ;  a  sixth  in  May ;  in  a  seventh  operation, 
in  June  of  the  same  year,  three  tumors  were  removed ;  but  from  the 
same  spot  two  more  arose,  and  these  grew  rapidly,  and  the  patient 
died. 

Now  if,  as  I  believe,  all  these  cases  and  others  that  I  have  seen, 
were  examples  of  the  proliferous  cystic  disease  of  the  breast,  they  prove 
such  an  inveterate  tendency  to  recurrence  in  this  disease,  as  is  scarcely 
surpassed  by  any  even  of  the  well-marked  malignant  tumors.  Unfortu- 
nately, no  examination  of  any  of  the  cases  was  made  after  death ;  so 
that  it  is  not  possible  to  say  whether  the  more  characteristic  features  of 
malignant  disease  existed,  such  as  the  concurrence  of  similar  disease  in 
internal  organs.  The  same  defect  does  not  exist  in  a  most  remarkable 
case  related  by  Dr.  Cooke.  J  The  patient  was  about  40  years  old  when, 
in  April,  1847,  six  ounces  of  a  glairy  brown  fluid  were  drawn  from  a 
cyst  in  her  breast,  which  formed  part  of  a  large  tumor  that  had  been 
growing  for  seven  months,  and  felt  in  some  parts  firm,  in  others  soft 
and  fluctuating.  Occasional  tappings  were  subsequently  employed ; 
but  after  five  or  six  weeks  the  integuments  inflamed  and  sloughed  over 
the  cyst,  and  a  profuse  discharge  of  similar  glairy  fluid  ensued.  "  Fun- 
goid masses"  soon  protruded,  and  in  July,  1847,  Dr.  Cooke  removed  the 
whole  disease.  It  weighed  3|  pounds,  and  consisted  of  fungoid  masses 
of  various  degrees  of  firmness,  with  a  central  cavity  lined  by  a  vascular 
membrane.     In  December  of  the  same  year,  a  small  enlargement  on  the 

*  Lectures  on  Pathology  and  Surgery,  p.  145. 

t  Archives  Gen.  de  Medecine,  Fevrier,  1844,  p.  186. 

J  Medical  Times  and  Gazette,  August  7,  1852. 


388  CANCEROUS    PROLIFBEOUS    CYSTS. 

scar  was  removed.  In  March  and  in  October  of  the  next  year  (1848), 
renewed  growths  were  again  removed.  In  1849  the  disease  again  re- 
turned, and  was  extirpated  in  June,  1850,  This  was  "  a  miniature 
representation  of  the  tumor  removed  at  first;"  and  it  was  examined  by 
Mr.  Birkett,  who  reported  of  it,  that,  "in  a  stroma  of  fibrous  tissue 
cysts  appeared,  containing  a  yellow  tenacious  fluid.  The  follicular 
terminations  of  ducts  of  glands  were  very  distinctly  seen  in  the  fibrous 
tissue,  and  nucleated  corpuscles  :  within  these  follicles  were  clearly  seen 
the  elements  of  the  epithelium  of  glands."  The  patient  recovered  rapidly 
from  this  last  operation,  and  no  recurrence  of  the  disease  in  the  breast 
again  ensued ;  but  in  June,  1851,  she  began  to  suifer  with  what  proved 
to  be  cancer  of  the  peritoneum,  liver,  pleura,  pelvic  organs,  and  lumbar 
and  thoracic  lymphatic  glands.  When  she  died,  in  IS'ovember,  1851, 
abundant  cancerous  disease  was  found  in  all  these  parts  :  but  the  seat 
of  former  disease  in  the  breast  was  healthy,  and,  as  Mr.  Birkett  es- 
pecially remarks,  all  the  lymphatic  glands  connected  with  the  breast 
were,  as  they  always  had  been,  unaflFected,  while  all  those  connected 
with  the  cancerous  parts  in  the  pelvis  and  elsewhere  were  the  seats  of 
cancer. 

The  fact  last  mentioned  makes  it  improbable  that  the  cancerous  dis- 
ease with  which  this  patient  died  was  continuous  with,  or  a  part  of,  the 
disease  which  had  been  manifested  in  the  breast.  Rather,  we  may 
believe  that  the  two  aifections  were  essentially  distinct,  and  that  the 
first  was,  like  the  others  I  have  related,  an  example  of  recurring 
proliferous  cystic  disease.  But  further  inquiries  are  necessary  to  eluci- 
date these  cases  ;  at  present,  they  are  obscure  in  all  but  their  practical 
import,  and  in  their  proof  that  the  cystic  disease  of  the  breast,  though 
generally  a  completely  innocent  disease,  is,  in  certain  cases,  pecu- 
liarly prone  to  recur  after  removal.  In  this  view  they  will  again  be 
referred  to,  in  the  lecture  on  recurrent  tumors,  and  in  the  lectures  on 
the  general  pathology  of  cancers. 

3.  It  may  be  inserted  here,  that  the  mode  of  growth  observed  in  the 
glandular  proliferous  cysts  may  be  imitated  by  genuine  cancerous 
diseases. 

Cancerous  growths  may  be  found  in  cysts  under  at  least  two  condi- 
tions ;  namely,  in  cysts  that  of  themselves  appear  innocent,  and  in 
cysts  produced  within  cancers. 

Of  the  former  mode  of  growth  we  have  the  examples  in  ovarian 
cysts,  to  which  I  just  referred ;  and  herein  are,  perhaps,  the  only  un- 
exceptionable instances  of  the  transformation  of  an  innocent  into  a 
malignant  tumor. 

The  second  mode  of  production  of  intra-cystic  cancers  is  best  shown 
in  some  examples  of  medullary  tumors  of  the  testicle.     In  these*  we 

*  As  in  Mus.  Coll.  Surg.,  No.  2396. 


CUTANEOUS    PROLIFEROUS    CYSTS.  389 

may  see  a  repetition,  so  far  as  the  plan  is  concerned,  of  the  intra-cystic 
production  of  thyroid  gland.  The  great  mass  of  the  medullary  disease 
includes  smaller  masses,  incapsuled  with  connective  tissue,  and  com- 
monly presenting  a  lobed  and  laminated  form,  at  once  reminding  us 
of  the  intra-cystic  glandular  growths,  and  justifying  the  application 
to  them  of  the  principles  of  Dr.  Hodgkin's  theory  of  the  growth  of 
cancers. 

In  these  medullary  testicles  the  intra-cystic  medullary  growths  have 
usually  filled  the  cysts  and  coalesced  with  their  walls.  In  rare  cases 
one  can  discern  how  the  growths  spring  up  as  spheroidal,  or  as  peduncu- 
lated, branching,  and  grouped  processes  from  the  interior  of  the  cysts. 
This  condition  was  peculiarly  well  shown  in  a  case  of  cancer  of  the 
clitoris,  in  which  the  whole  of  that  organ  was  occupied  or  concealed  by 
a  cancerous  mass  inclosing  several  distinctly  walled  cysts,  which  were 
half-filled  with  small,  soft,  and  lobed  cancerous  intra-cystic  growths.* 

4.  I  proceed  to  the  consideration  of  the  cutaneous  proliferous  cysts ; 
i.  e.  of  cysts  within  which,  in  the  typical  examples,  a  tissue  grows, 
having  more  or  less  the  structure  and  the  productive  properties  of  the 
skin. 

Instances  of  these  in  a  perfect  or  typical  state  are  rare.  In  the 
large  majority  of  cases  the  cutaneous  structure,  if  it  were  ever  present, 
has  degenerated  or  disappeared ;  and  we  recognize  the  relations  and 
import  of  the  cysts  only  through  their  containing  epidermal  and  sebace- 
ous materials,  of  which  the  natural  production  is  a  peculiar  attribute  of 
the  tissues  of  the  skin. 

Among  the  parts  in  which  these  skin-bearing  cysts  may  be  found  are 
some  that  have  no  natural  connection  with  the  skin. 

1.  They  are  frequent  in  the  ovaries ;  one  or  more  Graafian  vesicles 
enlarge  and  grow,  and  then,  apparently,  produce  on  their  inner  surface 
a  growth  of  skin,  with  its  layer  of  cutis,  subcutaneous  fat,  epidermis, 

*  Museum  of  St.  Bartholomew's,  Ser.  xxxii,  39.  Rokitansky  gives  to  cases  of  this  kind 
the  name  of  cysto-carcinoma,  and  draws  a  just  parallel  between  them  and  the  instances  of 
cyeto-sarcoma.  (Pathol.  Anat.  i,  p.  390.)  Cysto-sarcoma  he  regards,  nearly  following  Miiller 
herein,  as  a  combination  of  sarcoma  with  cyst-formation.  The  cases  included  by  him  and 
Miiller  (On  Cancer,  p.  170)  under  the  name,  cannot  be  all  inclosed  in  the  groups  which  1 
have  brought  near  together.  (1.)  Some  are  cases  in  which  simple  cysts  are  found  within 
solid  tumors:  these  are  named  cysto-sarcoma  simplex,  and  such  as  these  will  be  mentioned 
or  referred  to  as  varieties  of  fatty,  fibrous,  fibro-plastic,  and  cartilaginous  tumors,  in  all  of 
which  the  formation  of  cysts  may  ensue.  (2.)  The  cysto-sarcoma  proliferum.  if  it  be  cor. 
rectly  described  as  constructed  of  cysts  contained  in  a  solid  tumor,  and  containing  younger 
cysts  in  their  interior,  I  have  never  seen.  The  case  to  which  Miiller  refers  as  exemplifying 
it,  and  which  is  figured  by  Sir  A.  Cooper  (Illustrations,  p.  41,  pi.  iii),  was,  I  believe,  an  in- 
stance of  proliferous  glandular  cyst  in  the  mammary  gland.  (3.)  The  cysto-sarcoma  phyl- 
lodes  is  a  proliferous  glandular  cyst  of  the  breast,  and  is  especially  exemplified  by  the  cases 
in  which  the  intra-cystic  growths  are  firm,  lobed,  pedunculated,  and  clustered,  and  in 
which  many  cysts  are  close-set  in  the  breast.  But  in  this  disease  there  is,  I  think,  no  solid 
tumor  in  which  the  cysts  are  set:  they  appear  to  be  themselves  the  primary  disease,  the 
solid  growths  within  them  being  secondary  formations ;  and  if  this  be  true,  they  cannot 
properly  be  grouped  with  the  examples  of  MuUer's  cysto-sarcoma  simplex. 


390  CUTANEOUS    CYSTS. 

and  all  the  minute  appended  organs  of  the  proper  hairy  integuments  of 
the  body.  The  general  likeness  of  the  interior  of  these  cysts  to 
ordinary  skin  had  been  often  noticed  ;  but  the  first  minute  demonstra- 
tion of  it  was  by  Kohlrausch,*  whose  observations  have  been  fully  con- 
firmed by  others  as  well  as  by  myself.  Among  the  specimens  in  the 
College  Museum,  one  (No.  164  a)  presents  all  the  textures  of  a  hairy 
piece  of  skin  growing  on  the  interior  of  one  of  the  cavities  of  a  large 
multilocular  ovarian  cyst.  Of  the  other  divisions  of  the  same  cyst, 
some  contained  fatty  matter  and  loose  hair ;  others,  various  fluids  ; 
others,  secondary  and  tertiary  cysts :  and  this  is  commonly  the  case. 
Another  specimen  in  the  College  Museum  (No.  2624)  shows  very  well 
the  origin  of  these  skin-bearing  cysts.  It  is  an  ovary,  with  a  cyst,  the 
small  size  of  which,  as  well  as  the  structure  of  its  walls,  and  the  mode 
in  which  they  are  connected  with  the  ■  surrounding  substance  of  the 
ovary,  leaves  no  doubt  that  it  is  a  simply  enlarged  Graafian  vesicle. 
Yet  it  contains  some  hairs,  and  a  small  mass  of  fat,  resembling  the 
subcutaneous  fat,  with  its  tougb  connective-tissue  partitions. 

2.  Cutaneous  proliferous  cysts  may  form  in  the  subcutaneous  tissue. 
They  are,  indeed,  rare  in  this  tissue  in  man,  except  in  cases  of  con- 
genital growths.  In  the  little  cysts  about  the  brow,  or  in  or  near  the 
orbit,  the  inner  surface  is  often  perfectly  cutaneous ;  and  Lebertf  has 
detected  in  such  cysts  all  the  minute  structures  and  organs  of  the  skin.| 
Most  of  these  cysts  are  first  observed  at  or  soon  after  birth.  Some 
similar  specimens  of  cysts  lined  with  skin  are  in  the  Museum  of  the 
College. §  These  were  taken  from  the  subcutaneous  tissue  of  a  cow 
and  of  an  ox ;  and,  in  some  of  them,  the  inner  surface  of  the  cyst 
could  hardly  be  distinguished  from  the  outer  hairy  integument  of  the 
animal.  II 

3.  Besides  these,  the  common  seats  of  cutaneous  cysts,  perhaps  any 
part  or  organ  may  in  rare  instances  present  them ;  for  the  records  of 
surgery  and  pathology  would  furnish  abundant  instances  of  aberrant  cysts 
containing  hair  and  fatty  matter,  such  as  we  must  class  with  these  in 
which  the  cutaneous  structure  and  products  are  more  perfect.  The  most 
singular  and  frequent  of  these  rarer  examples  are  in  the  testicle,^  the 

*  Miiller's  Archiv,  1843,  p.  365,  A  careful  description  of  the  structure  of  these  skin- 
bearing  cysts  in  the  ovary,  by  Dr.  Steinlein,  may  be  found  in  the  Zeitsch.  f  Rat.  Med.,  vol. 
ix,  p.  146. 

f  Abhandlungen,  p.  99,  e.  s.  The  structure  is  well  shown  in  No.  158  in  the  College 
Museum. 

X  Mr.  H.  Walton,  in  his  "  Remarks  on  Tarsal  Tumors"  (Med.  Chir.  Trans.,  xxxvii,  p.  7, 
18.54),  suggests  that  the  name  of  Meibomian  cysts  should  be  given  to  the  so-called  tarsal 
tumors.  He  considers  them  to  be  dilated  and  grown  Meibomian  glands,  with  cuticular,  or 
sebaceous,  or  degenerate,  or  puriform  contents,  and  sometimes  with  vascularized  and  per- 
haps glandular  intra-cystic  growths. 

§  Nos.  161,  16.3,  &c. 

II  In  Mi)s.  St.  Bar.  is  a  specimen  of  a  cutaneous  cyst,  containing  hair,  obtained  from  the 
scalp.     See  Med.  Times  and  Gaz.,  Dec.  16,  1853. 

IT  See  Goodsir,  in  Edinb.  Monthly  Journal,  June,  1845. 


SEBACEOUS    AND    EPIDERMAL    CYSTS.  391 

lung,*  the  kidney,t  the  bladder  ;J  and  under  the  tongue,§  and  within 
the  skull  or  brain.  Those  in  the  brain  are  of  chief  interest.  I  found 
one||  many  years  ago  in  an  elderly  man.  While  he  was  in  St.  Bar- 
tholomew's Hospital  with  an  ulcerated  leg,  he  suddenly  died ;  and  the 
only  probable  cause  of  death  appeared  to  be  a  mass  of  granular  fatty 
matter  mixed  with  short  stiff  hairs,  which  lay  in  the  tissue  of  the  pia 
mater  under  the  cerebellum, 

A  yet  more  remarkable  case  is  in  the  Museum  of  St.  George's  Hos- 
pital, in  Mr.  Caesar  Hawkins's  collection.  It  exhibits  a  mass  of  fatty 
matter,  and  a  lock  of  dark  hair  1|  or  2  inches  long,  attached  to  the 
inner  surface  of  the  dura  mater  at  the  torcular  Herophili.  This  was 
found  in  a  child  two  and  a  half  years  old,  in  whom  it  appeared  to  have 
been  congenital.^ 

It  is  perhaps  only  during  the  vigor  of  the  formative  forces  in  the 
foetal  or  earliest  extra-uterine  periods  of  life,  that  cysts  thus  highly  or- 
ganized and  productive  are  ever  formed.  The  sebaceous,  epidermal,  or 
cuticular  cysts  that  grow  in  later  life  are  imperfect,  impotent  imitations 
of  these ;  yet  clearly  are  the  same  disease,  and  are,  therefore,  most 
naturally  classed  with  the  proliferous  cysts,  needing  only  to  be  named 
according  to  their  contents.  We  cannot  tell,  in  any  advanced  case  of 
such  a  cyst,  whether  the  more  complicate  structures  of  the  skin  ever 
existed ;  if  they  did,  they  have  degenerated  before  the  cyst  became  of 
distinct  size ;  yet  the  retained  likeness  is  sometimes  shown  in  the  fact 
that,  when  such  cysts  are  laid  open  to  the  air,  they  do  not  granulate, 
but  assume  for  their  internal  surfaces  the  characters  of  the  adjacent 
and  now  continuous  skin.** 

Of  these  sebaceous  or  epidermal  cysts,  it  is  interesting  to  notice  the 
frequent  hereditary  origin.  Perhaps,  in  the  majority  of  cases,  the 
bearers  of  these  have  known  one  or  more  members  of  their  family  simi- 
larly endowed.  They  are  certainly  more  commonly  hereditary  than 
are  any  forms  of  cancer. 

I  have  already  referred  to  the  double  mode  of  origin  of  the  epidermal 

*  KoUiker,  in  the  Zeitschrift  fiir  wisserisch.  Zoologie,  B.  ii,  p.  281.  Cloetta  in  Vircbow's 
Archiv,  vol.  xx,  p.  42,  1860. 

t   Mus.  Coll.  Surg.  1904.  %  Mus.  Coll.  Surg.  2626. 

I  Schuh,  Pseudoplasmen,  p.  154;  and  Mus.  St.  Bartholomew's,  Ser.  xxxv,  No.  25.  Hut- 
chinson. Med.  Times  and  Gaz..  Dec.  31,  1853. 

II  Mus.  St.  Bartholomew's,  Ser.  vi,  56. 

1[  Dr.  J.  Ogle  has  carefully  described  this  specimen  in  the  Trans.  Path.  Soc,  vol.  vi,  p. 
12.  He  is  of  opinion  that  the  cyst  was  originally  of  extra-cranial  formation,  but  that  at 
an  early  period  of  festal  life,  before  ossification  of  the  occipital  bone  had  taken  place,  the 
cerebral  membranes  and  scalp  had  become  adherent,  and  that  as  the  development  of  the 
bone  went  on,  the  outer  integument  was  drawn  in  by  retirement  of  the  cerebral  mem- 
branes. In  this  way  some  of  the  cutaneous  structures  would  become  included  within  the 
cranium.  He  considers  tliat  the  cyst  possesses  characters  which  warrant  the  above  sup- 
position. In  a  similar  manner,  perhaps,  cysts  within  the  orbit  may  extend  into  the  craniaL 
cavity. 

**  See  Home,  Hunter's  Works,  vol.  iii,  p.  635 ;  and  a  remarkable  case  by  Mr.  Green,  in, 
the  Medical  Gazette,  vol.  ii,  p.  346. 


392  SEBACEOUS    AND     EPIDEEMAL    CYSTS. 

cysts.  Sir  Astley  Cooper  first  observed  that  some  among  them  could 
be  emptied,  by  pressing  their  contents  through  a  small  aperture  in  the 
cutis  over  them,  and  hence  concluded  that  they  are  all  examples  of 
hair-follicles  distended  with  their  secretions,  and  overgrown  :  but  pro- 
bably this  conclusion  is  true  for  only  a  minority  of  these  cysts.  They 
are,  I  think,  comparatively  few,  in  which  an  aperture  can  be  found;* 
the  greater  part  are  closed  on  all  sides  alike,  and  must  be  regarded  as 
cysts  new-formed.  I  suspect  that  those  cases  are  equally,  or  more  rare, 
of  which  Lebert  and  Bruns  have  described  instances,f  characterized 
by  the  existence  of  a  slender  cord,  traceable  from  the  cyst  to  the  skin, 
and  formed  of  the  obliterated  duct  of  the  enlarged  and  obstructed  air- 
follicles. 

The  characters  of  these  epidermal  cysts  may  be  extremely  various, 
in  regard  not  only  to  their  walls,  but  to  their  contents.  Their  walls 
may  be  thin,  delicate,  and  pliant ;  or  laminated,  thick,  and  hard,  with 
tough  fibrous  tissue ;  or  they  may  be  calcified;  and  I  believe  a  general 
rule  may  be  connected  with  the  differences  in  these,  as  in  other  cysts, 
namely,  that  the  thin-walled  are  the  most  productive,  grow  most  rapidly, 
and  are  the  seats  of  the  most  active  change.  | 

*  Mr.  South  especially  notices  tliis  in  his  edition  of  Chelius's  Surgery,  vol.  ii,  p.  698.  See 
also  Walther,  in  Vogel's  Pathol.  Anat.  p.  224.  Professor  Porta,  in  an  essay  devoted  to  the 
consideration  of  follicular  sebaceous  tumors  (Dei  Tnmori  Folliculari  Sebacei,  Milano,  1856), 
agrees  with  this  statement.  He  supplies  some  statistical  information  respecting  the  fre- 
quency of  occurrence  of  the  different  kinds  of  cysts.  He  has  met  with  384  specimens;  23 
patients,  having  from  2  to  20  cysts  each,  supplied  72  of  the  specimens.  Of  the  384  cysts, 
270  were  on  the  head  and  face,  114  on  other  parts  of  the  body,  257  were  subcutaneous;  127 
(including  37  encysted  hydroceles)  were  deep  seated,  41  were  congenital,  the  others  originated 
at  various  times  of  life,  and  had  various  progress.  Of  the  384  cases,  238  were  examples  of 
cutaneous  cysts  of  new  formation,  78  (including  those  of  encysted  hydroceles)  were  cases 
of  hygroma,  15  were  hsematoid  or  sanguineous  cysts,  9  calcareous  cysts,  4  echinococcus 
cysts,  14  suppurated  cysts,  and  26  were  such  sebaceous  follicular  cysts  as  he  has  made  the 
chief  subject  of  his  essay.  Of  these  last-named  he  describes  cases  of  a  kind  of  cutaneous 
tumor  of  the  face,  composed  chiefly  of  numerous  hair-follicles,  or  sebaceous  glands,  arranged 
in  groups  and  all  moderately  enlarged  (see  hisPl.iii). 

f   Virchow's  Archiv,  viii,  H.  ii,  p.  222. 

J  Wernher,  in  Virchow's  Archiv,  viii,  p.  221,  has  described  the  walls  of  the  epidermal 
cysts  as  possessing  a  more  complicated  structure  than  has  been  hitherto  recognized.  Ex- 
cluding those  formed  of  dilated  hair-follicles,  which  are  very  few,  he  states  that  the  cysts 
have  two  layers  in  their  walls:  an  external  formed  of  connective  tissue,  and  an  internal,  in 
places  thin  and  membranous,  but  in  others  much  thicker,  irregular,  or  like  cartilage.  Im- 
bedded in  the  substance  of  the  internal  cyst-wall,  especially  in  its  thick  nodular  parts,  are 
collections  of  laminated  epidermal  capsules,  and  in  some  instances  all  the  other  usual  con- 
tents of  epidermal  cysts.  In  the  later  stages  of  the  growth  the  structures  imbedded  in  the 
cyst-walls  may  become  inclosed  in  thin  cysts,  which  may  afterwards  split  and  gradually 
discharge  their  contents  into  the  main  cyst  cavity,  in  which  case  they  are  found  as  heaps  of 
epidermal  structures,  set  on  the  surface  of  the  outermost  layer  of  the  epidermal  contents  of 
the  main  cyst.  When  thus  emptied,  the  inner  surface  of  the  inner  layer  of  the  cyst-wall  has 
cavities,  or  reticulated  depressions,  corresponding  to  the  emptied-out  collections  of  epider- 
mal structures.  It  may  be,  however,  a  question  whether  the  interpretation  put  by  Wern- 
her on  these  collections  of  epidermal  structures  within  the  innermost  layer  of  the  cyst-wall, 
viz.,  that  they  are  first  formed,  and  subsequendy  encysted,  is  the  correct  one.  It  is  more 
probable  that  they  are  abortive  or  imperfect  follicular  structures,  representing  the  completely 
formed  follicles,  glands,  &c.,  of  the  best  and  most  perfect  cutaneous  cysts. 


SEBACEOUS    AND    EPIDERMAL    CYSTS.  393 

Among  the  contents  of  these  cysts  we  may  observe  extreme  varie- 
ties. The  chief  alone  need  be  referred  to.  And  1st,  we  find  successive 
productions  of  epidermis,  formed  in  layers  on  the  inner  wall  of  the  cyst, 
and  thence  successively  shed,  and  pushed  inwards  towards  its  centre. 
A  section  of  such  cysts  (which  were  particularly  described  by  Sir  Eve- 
rard  Home  from  the  Hunterian  specimens)  presents  layers  of  white  soft 
epidermis,  like  macerated  epidermis  of  the  heel  or  palm.  The  external 
layers  are  commonly  quite  regular,  white,  and  flaky ;  but  the  internal 
are  more  disorderly,  as  if  degenerate,  broken  up,  or  liquefied,  and  min- 
gled with  less  organized  productions. 

2dly.  A  peculiar  appearance  is  given  to  contents  like  these,  where, 
among  the  layers  of  epidermal  scales,  abundant  crystals  of  cholesterine 
are  mingled.  They  hence  derive  an  appearance  like  that  of  the  masses 
to  which  Muller*  has  given  the  name  of  cholesteatoma,  or  laminated 
fatty  tumor ;  and,  indeed,  the  few  well-marked  examples  of  this  disease 
which  I  have  been  able  to  examine,  as  well  as  Miiller's  own  account, 
make  me  think  that  what  he  named  cholesteatoma  is  only  a  combina- 
tion of  layers  of  epidermal  scales  with  crystals  of  cholesterine.f 

The  appearance  produced  by  such  a  combination  is  quite  peculiar. 
It  forms  nodular  masses  of  soft  and  brittle  substance,  like  wax  or  sper- 
maceti, the  surfaces  of  which  present  a  bright  glistening,  like  that  of 
mother-of-pearl,  Avhile  their  sections  are  finely  laminated.  It  is  a  rare 
disease  ;  the  most  frequent  seats  of  well-marked  specimens  appearing 
to  be  in  ovarian  cysts,  and  in  connection  with  the  membranes  of  the 
brain.  The  characters  are  well  shown  in  the  contents  of  a  small  ova- 
rian cyst  in  St.  Bartholomew's  Hospital ;  and  in  the  tumor  within  the 
occipital  part  of  the  cranium,  in  Mr.  Hawkins's  collection,  to  which  I 
have  already  referred.  Striking  examples  are  figured  by  Cruveilhier  ;i 
but  the  want  of  microscopic  examination  leaves  their  constitution  un- 
certain. 

Bdly.  In  the  opposite  extreme  to  these  cysts,  in  which  the  cuticular 
product  is  most  perfect,  we  find  an  innumerable  variety  of  contents,  of 

*  On  Cancer,  p.  155. 

•j-  See,  also,  an  account  of  such  a  case  by  Mr.  W.  Adams,  in  Proc.  of  Pathol.  Soc,  1850-1. 
Other  writers  since  Miiller  have  applied  the  nanne  of  cholesteatoma  more  vaguely.  Vir- 
chovs^,  in  an  essay  in  his  Archiv,  B.  viii,  p.  371,  1S55,  shows  the  need  of  distinguishing,  more 
than  is  commonly  done,  the  true  cholesteatoma  of  Miiller  from  mere  collections  of  chole- 
sterine crystals  in  cysts,  dried-up  abscesses,  surfaces  of  ulcers,  &c.  He  terms  the  true  chole- 
steatoma Perl-geschwulst,  "  pearly  tumor,"  and  points  out  that  its  essential  characters  are  con- 
centrically laminated,  flat  epidermoid  cells,  with  interspersed  cholesterine  crystals.  He 
admits  the  similarity  between  some  cases  of  cholesteatoma  and  the  cutaneous  proliferous 
cysts,  but  is  of  opinion  that  there  are  others,  and  he  cites  two  which  grew  in  the  pia  mater 
which  came  under  his  own  observation,  to  which  no  such  cutaneous  origin  could  be  as- 
cribed. He  gives  also  cases  of  cystic  tumors  in  the  testicle  in  which  cholesterine  pearls 
were  found.  He  thinks  that  in  such  cases  they  may  be  formed  from  the  epithelial  struc- 
tures of  the  seminal  tubes.  An  illustrative  case  in  the  scalp  is  recorded  by  Volkmann  in 
Virchow's  Archiv,  vol.  xiii,  p.  46,  1858. 

I  Anatomic  Pathol.,  liv.  ii,  p.  6.  • 

26 


394  SEBACEOUS    AND    EPIDERMAL    CYSTS. 

buff-  and  ochre-yellow,  and  brownish  materials,  that  seem  to  consist 
mainly  of  degenerate  cuticle  mingled  with  sebaceous  secretions.  The 
microscope  finds  in  them  a  confused  mass  of  withered  scales,  of  granular 
fatty  matter,  clustered  and  floating  free,  of  cholesterine  crystals,  and 
of  earthy  matter  in  free  molecules,  or  inclosed  within  the  cells  or  scales. 
And  all  these  may  be  floating  in  a  turbid  liquid,  or  retained  in  some 
soft  tenacious  mass,  or  clustered  in  hard  nodular  and  pointed  masses, 
projecting  like  stalactites  from  the  old  cyst-walls.* 

One  more  phase  of  this  disease  deserves  especial  notice, — that  in  which 
the  cyst  ulcerates,  and  its  contents  protrude.  An  inflammation  in  or 
about  the  sac  often  appears  the  inducement  to  this  change ;  and  some- 
times the  inflammation  itself  can  be  traced  to  nothing  but  disturbance 
of  the  general  health.  The  probability  that  it  may  thus  arise  makes 
the  caution  very  valuable  which  Dr.  Humphryf  gives  concerning  the 
removal  of  all  tumors.  "It  is  always  well"  (he  says)  "to  bear  in  mind 
that  persons  are  most  likely  to  consult  us  respecting  these,  or  other 
growths  of  the  like  kind,  when'  they  are  out  of  health,  and  consequently 
unfit  to  bear  an  operation:  they  do  so  because  the  tumor  is  then  most 
productive  of  pain  and  annoyance." 

A  distressing  instance  of  the  truth  of  this  occurred  to  myself  several 
years  ago.  A  strong  but  very  intemperate  man  came  to  me  as  an  out- 
patient, with  an  ulcerated  sebaceous  cyst,  about  three-quarters  of  an 
inch  in  diameter,  just  below  and  to  the  right  of  the  umbilicus.  He  had 
observed  a  tumor  here  for  16  years  ;  but  he  had  scarcely  thought  of  it 
till,  during  the  last  five  weeks,  it  had  grown  quickly,  and  in  the  last 
fortnight  had  ulcerated.  I  saw  no  reason  to  be  very  cautious  in  such 
a  case ;  so  slit  the  tumor  and  removed  it,  as  well  as  the  thickening  and 
adhesion  of  the  parts  around  would  allow.  In  the  evening,  having 
returned  to  his  work  and  some  intemperance,  hemorrhage  ensued  from 
a  small  cutaneous  vessel,  and  before  he  reached  the  hospital  he  lost 
more  than  a  pint  of  blood.  I  tied  the  artery,  and  applied  solution  of 
alum  to  the  rest  of  the  wound,  for  its  whole  surface  was  oozing  blood, 
and  he  was  admitted  into  the  hospital.  The  next  day  he  became  very 
feverish,  and  he  appeared  as  if  he  were  going  to  have  typhus,  which 
was  then  prevalent.  But  from  this  state  he  partially  recovered ;  and 
then  abscesses  formed  in  his  groins,  and  discharged  profusely.  Nothing 
improved  his  health,  and  three  months  after  the  operation  he  died,  ap- 
parently exhausted  by  the  continual  discharge  from  the  abscesses,  and 
with  both  external  epigasti'ic  veins  and  parts  of  the  femoral  veins  full 
of  old  clotted  blood — the  consequence  of  slow  phlebitis. 

Cases  like  this,  or  ending  fatally  much  sooner  than  this  did,  with 
erysipelas  or  more  acute  phlebitis,  have  occurred  to  many  surgeons. 
They  need  no  comment  to  make  them  instructive. 

*  College  Museum,  157  A  and  2297.     A  most  remarkable  specimen  is  in  the  Museum  of 
Guy's  Hospital,  which  was  removed  from  an  old  man's  thigh, 
t  Lectures  on  Surgery,  p.  135;  from  the  Provincial  Medical  and  Surgical  Journal. 


DENTIGEROUS    CYSTS.  395 

I  believe  the  contents  thus  protruded  from  cutaneous  cysts  may  be- 
come vascular.  I  have  not  seen  this  event,  but  it  seemed  certain  in  a 
case  observed  by  Mr.  James  Reid.  A  woman,  80  years  old,  had  nume- 
rous cysts  in  her  scalp.  They  were  like  common  sebaceous  cysts ;  and 
three  of  her  daughters  had  cysts  like  them.  Two  years  and  a  half 
before  her  death,  one  of  the  cysts,  which  had  not  previously  appeared 
different  from  the  rest,  inflamed.  It  was  opened,  and  sebaceous  matter 
was  discharged  from  it.  The  opening  did  not  heal,  but  ulcerated,  and 
a  small  hard  lump  remained  under  the  ulcer  for  a  year,  when,  after 
erysipelas  of  the  head,  it  began  to  grow,  and  rather  quickly  increased 
to  a  mass  nearly  five  inches  in  diameter,  which  occasionally  bled  largely. 
The  mass  has  the  appearance  of  the  firm  contents  of  a  cuticular  and 
sebaceous  cyst,  and  contains  abundant  epidermal  cells;*  so  that  there 
can  be  scarcely  a  doubt  that  it  had  its  origin  in  the  contents  of  such 
a  cyst. 

5.  Concerning  cysts  containing  teeth,  a  few  words  must  suffice.  They 
are  of  two  kinds.  Some,  occurring  in  the  ovaries,  and  more  rarely  in 
other  parts,  bear,  with  one  or  more  teeth,  the  products  of  skin,  as  hair, 
epidermis,  &c.t  These  may  be  regarded  as  diseases  of  the  same  general 
group  with  the  cutaneous  proliferous  cysts ;  and  the  great  formative 
power  which  they  manifest  is  consistent  with  their  occurring  only  in 
embryonic  or  foetal  life,  and  in  the  ovaries,  in  which,  even  indepen- 
dently of  impregnation,  one  discovers  so  many  signs  of  great  capacity 
of  development. 

Other  dentigerous  cysts  occur  within  the  jaws.  In  some  cases,  cysts 
are  hollowed  out  in  the  substance  of  the  upper  or  lower  jaw,  and  are 
lined  with  a  distinct  membrane,  to  some  part  of  which  a  tooth  is  at- 
tached. I  believe  these  are  examples  of  tooth-capsules,  from  which  the 
teeth,  though  perfectly  formed,  at  least  in  their  crowns,  are  not  ex- 
truded, and  which  therefore  remain,  becoming  filled  with  fluid,  and 
growing  larger. J  In  other  cases,  that  which  appears  as  a  cyst  is  the 
antrum,  distended  with  fluid,  and  having  a  tooth  imbedded  in  some  part 

*  Museum  of  St.  Bartholomew's  Hospital,  Series  xxxv,  No.  57.  Probably  the  case  was 
similar  which  is  related  by  Mr.  Abernethy  in  his  Essay  on  Tumors,  p.  117.  Such  cases 
have  peculiar  interest  in  relation  to  the  question  of  the  possible  origin  of  certain  epithelial 
cancers  in  these  cysts.     This  will  be  referred  to  in  Lecture  xxxii. 

f  A  very  remarkable  specimen  is  in  the  Museum  of  St.  Bartholomew's  Hospital  (Mal- 
formations, A  177).  It  was  presented  by  Mr.  Kingdon,  and  is  described  by  Dr.  Gordon  in 
the  Med.-Chir.  Trans.,  vol.  xiii.  In  the  anterior  mediastinum  of  a  woman  twenty-one  years 
old,  a  tumor,  probably  of  congenital  origin,  contained  portions  of  skin  and  fat,  serous  fluid, 
and  sebaceous  matter,  and  two  pieces  of  bone  like  parts  of  upper  jaws,  in  which  seven 
well-formed  teeth  were  imbedded.  In  an  ovarian  tumor,  more  than  300  teeth  were  once 
found :  in  another  case,  a  piece  of  bone,  like  part  of  an  upper  jaw.  with  44  teeth.  See 
Lang,  in  the  essay  cited  below,  p.  11. 

%  Two  such  cases  are  in  the  Museum  of  St.  Bartholomew's,  Series  i,  119,  119  a.  I  saw 
a  third  cured  by  Mr.  Wormald  by  cutting  away  part  of  the  cyst,  and  removing  the  tooth. 


396  FATTY    TUMORS. 

of  its  wall,  and  projecting  into  its  cavity.*  In  the  most  remarkable 
case  of  the  kind,  Professor  Baum  removed  a  tooth  from  each  antrum  of 
a  woman  38  years  old.  The  distension  of  the  antra,  with  excessive 
thickening  of  their  lining  membranes,  and  thinning  of  their  osseous 
walls,  and  with  accumulations  of  purulent  fluid,  had  been  in  progress 
for  thirty  years,  and  produced  horrible  deformity  of  the  face.  The 
operation  was  completely  curative. 


LECTURE    XXIY. 

FATTY   AND    FIBRO-CELLULAR   TUMORS  :    PAINFUL    SUBCUTANEOUS 

TUMORS. 

Among  the  solid  tumors,  the  first  that  may  be  considered  is  the  fatty 
or  adipose  tumor,  the  Lipoma  of  some,  the  Steatoma  of  others ;  the 
most  simple  in  its  texture,  the  most  like  the  natural  parts,  the  least 
liable  to  variations ;  a  morbid  growth  so  well  known,  that  I  can  scarcely 
hope  to  impart  any  interest  to  an  account  of  it. 

Among  the  growths  commonly  included  as  fatty  tumors,  we  find  ex- 
amples of  both  the  forms  of  morbid  hypertrophies  of  which  I  spoke  in 
the  twenty-first  lecture.  There  are  both  continuous  and  discontinuous 
morbid  hypertrophies  of  fat ;  both  fatty  outgrowths  and  fatty  tumors, 
more  properly  so  called,  f 

The  Fatty  Outgrowth  is  thus  described  by  Sir  B.  C.  Brodie,  in  his 
well-known  lecture  upon  fatty  tumors.  He  says, — "  There  is  no  distinct 
boundary  to  it,  and  you  cannot  say  where  the  natural  adipose  structure 
ends,  and  the  morbid  growth  begins.  .  .  .  These  tumors  feel  like  fat, 
but  they  may  be  distinguished  from  common  fatty  tumors  by  their 
having  no  well-defined  boundary,  and  by  their  being  less  soft  and 
elastic.  Such  deposits  may  take  place  in  any  part  of  the  body  ;  but  I 
have  seen  them  more  frequently  in  the  neck  than  anywhere  else."| 
Doubtless  the  case  will  be  familiar  to  you  by  which  Sir  B.  C.  Brodie  il- 
lustrates this  account, — the  case  of  a  footman,  with  an  enormous  double 
chin,  and  a  great  mass  of  fat  extending  from  ear  to  ear,  who  was  cured 
by  the  liquor  potasses.  The  case  already  cited  from  Schuh's  essay  (p. 
340),  was  of  the  same  kind. 

I  can  add  nothing  to  this  account,  except  the  mention  of  a  singular 

*  The  principal  cases  are  collected  in  two  essays,  for  which  I  have  to  thank  Professor 
Baum;  namely,  Lang,  Ueber  das  Vorkommen  von  Zahnen  im  Sinus  maxillare;  Tiibingen, 
1844;  and  Glasewald,  De  Tumore  quodam  utriusque  Antri  Highmori :  Gryphise,  1844. 
Three  good  cases,  also,  are  related  by  Mr.  Salter  in  the  Guy's  Hospital  Reports  for  1859. 

f  M.  Lebert  (Abhandlungen,  p.  112)  distinguishes  the  fatty  tumors,  according  to  their 
degrees  of  isolation,  as  Lipoma  circumscriptum  and  L.  diffusum. 

X  Lectures  on  Pathology  and  Surgery,  p.  275. 


FATTY    TUMORS.  397 

case  of  fatty  growth  connected  with  the  heart  of  a  sheep.*  The  right 
ventricle  is  nearly  filled  with  a  lobulated  mass  of  fat,  distending  it,  and 
pressing  back  the  tricuspid  valve.  The  left  auricle  and  ventricle  are 
similarly  nearly  filled  with  fatty  growths,  and  fat  is  accumulated  on  the 
exterior  of  the  heart,  adding  altogether  about  twenty-five  ounces  to  its 
weight.  The  textures  of  the  heart  itself  appear  healthy,  though  it  is 
the  seat  of  all  these  fatty  growths. 

The  discontinuous  Fatty  Tumors,  of  which  alone  I  shall  now  speak, 
present  a  tissue  exactly  or  very  nearly  resembling  the  normal  fatty  or 
adipose  tissue  of  the  animal  in  which  they  grow.  Certain  differences 
may,  indeed,  be  sometimes  found  between  the  fat  of  a  tumor  and  that 
of  the  part  in  which  it  lies;  such  as  the  larger  size  of  the  tumor's  cells, 
its  less  or  greater  firmness  at  the  same  temperature,  and  the  usual  crys- 
tallizing of  the  margarine ;  but  I  believe  there  are  no  greater  differ- 
ences than  may  be  found  in  the  natural  fat  of  different  parts  of  the 
same  person. 

It  would  be  superfluous  to  describe  or  delineate  the  minute  characters 
of  this  well-known  tissue :  it  is  only  in  its  arrangement  that  the  tumors 
have  any  peculiarity  worth  notice.  It  is,  in  all,  composed  essentially 
of  clustered  oil-cells ;  but  these  are,  in  some  tumors,  placed  in  a  uni- 
form mass,  smooth  on  its  surface,  and  only  obscurely  partitioned ;  in 
others,  arranged  in  oval  or  pyriform  lobes,  projecting  on  the  surface, 
easily  separable  by  splitting  their  connective-tissue  partitions;  and  in 
some  of  these  it  may  be  dissected  into  thin  layers,  which  are  wrapped 
in  each  lobe,  one  within  the  other,  like  the  leaflets  of  a  bud.  Moreover, 
any  of  these  forms,  whether  "simple,"  or  "  lobed,"  or  "involuted," 
may  be  either  deeply  imbedded  in  the  tissues,  or  "pendulous." 

Fatty  tumors  are,  I  believe,  always  invested  with  a  capsule,  or  cover- 
ing of  connective  tissue ;  and  of  these  capsules,  since  they  exist  with 
most  of  the  innocent  tumors,  I  may  speak  now  once  for  all.  The  cap- 
sule, then,  of  such  a  tumor  is  usually  a  layer  of  fibro-cellular,  areolar, 
or  connective  tissue,  well-organized,  dry,  and  containing  bloodvessels 
proportioned  to  the  size  of  the  tumor.  It  appears  to  be  formed  of  the 
connective  tissue  of  the  part  in  which  the  tumor  grows,  increased,  and 
often  strengthened,  in  adaptation  to  the  bulk  and  other  conditions  of 
what  it  incloses.  It  grows  with  the  tumor,  invests  it,  and  at  once  con- 
nects it  with  the  adjacent  tissues,  and  separates  it  from  them  ;  just  as, 
e.  g.,  similar  connective  tissue  does  each  muscle  in  a  limb.  Its  adhesion 
to  both  the  tumor  and  the  parts  around  it  is  more  intimate  than  that 
of  its  layers  or  portions  to  one  another ;  so  that  when  such  a  tumor  is 
cut  into,  it  may  be  dislodged  by  splitting  its  capsule,  and  leaving  some 
of  it  on  the  tumor,  and  some  in  the  cavity  from  which  the  tumor  is  ex- 
tracted. This,  at  least,  can  be  easily  done  unless  the  tumor  has  been 
the  seat  of  inflammation,  which  may  thicken  the  capsule  and  make  all 

*  Mus.  Coll.  Surg.,  1529. 


398  FATTY    TUMORS. 

its  parts  adherent  to  one  another,  and  to  the  tissues  on  either  side  of  it. 
As  Schuh  observes,  when  a  fatty  tumor  is  just  under  the  skin  its  cap- 
sule is  usually  more  closely  connected  with  the  skin  in  the  interspaces 
between  the  lobes  than  in  any  other  part,  so  that  the  skin  appears 
dimpled  over  it,  especially  if  one  squeezes  the  tumor  at  its  base,  and 
presses  it  up  to  make  the  skin  tense. 

In  the  capsule,  the  bloodvessels  that  supply  the  tumor  usually  first 
ramify.  One  principal  artery,  indeed,  commonly,  but  not  always, 
passes  straightway  into  the  tumor  at  its  deepest  part,  but  the  rest 
branch  in  the  capsule,  especially  in  any  thicker  parts  of  it  that  lie  in 
the  spaces  between  projecting  lobes  of  the  tumor.  Hence,  with  the 
partitions  of  the  tumor  that  are  derived  from  the  capsule,  the  blood- 
vessels pass  into  its  substance. 

The  capsules  of  these  fatty  tumors  may  vary  somewhat  in  thickness 
and  toughness ;  and  so  may  the  partitions  that  proceed  from  them  into 
the  mass.  They  are  usually  very  delicate ;  but  they  are  sometimes 
thick  and  strong,  and  give  a  density  and  toughness  which  approach  to 
the  characters  of  a  fibrous  tumor.  To  such  examples  of  fatty  tumors 
deviating  from  the  common  type,  Miiller*  has  assigned  the  name  of 
Lipoma  mixtum;  and  Yogeljf  Gluge,|  Rokitansky,§  and  some  others, 
call  them  "  steatoma,"  and  "  lardaceous  tumor"  (Speckgeschwiilst).]! 

Fatty  tumors  usually  occur  singly ;  but  there  are  many  exceptions 
to  this  rule.  Two  or  three  in  the  same  person  are  not  rarely  seen,  and 
a  hundred  or  more  may  exist.  Sir  B.  C.  Brodie  mentions  such  cases  ; 
and  I  am  acquainted  with  a  gentleman,  who  has  borne,  for  nearly  twenty 
years,  firm  tumors,  feeling  like  fatty  masses,  in  the  subcutaneous  tissue 
of  his  trunk  and  all  his  limbs.  They  are  usually  stationary,  but  some- 
times one  grows  a  little,  or  one  diminishes,  or  a  new  one  appears. 
Lately,  I  have  seen  a  woman,  50  years  old,  in  whom  a  large  number  of 
similar  tumors  had  been  growing  for  about  ten  years  in  the  subcuta- 
neous tissue  of  the  arms,  thighs,  and  haunches.  They  were  all  small 
and  firm,  and  felt  like  tumors  of  mixed  fatty  and  tough  connective 
tissue. 

The  most  frequent  seats  of  fatty  tumors  are  the  trunk,  and  the  part 
of  the  neck  and  limbs  that  are  nearest  to  it ;  but  they  may  occur  in 
any  part  where  fat  naturally  exists,  and  they  are  not  limited  even  to 
these. T[     It  is,  perhaps,  impossible  to  say  why  they  should  afi"ect  one 

*  On  Cancer,  p.  153.  f  Pathologische  Anatomic,  p.  179. 

'I  Pathologische  Anatomie.  §   Pathologische  Anatomie,  B.  i,  p.  283. 

II  Miiller  also  gives  the  name  of  Lipoma  arborescens  to  the  pendulous  fatty  processes 
with  synovial  membrane  that  are  clustered  about  chronic  diseased  joints.  Sir  B.  C.  Brodie 
(Lectures,  1.  c.)  describes  a  form  of  fatty  tumor,  which  I  have  not  yet  seen,  in  which  the 
tumor  is  covered  with  a  double  layer  of  membrane,  like  a  serous  sac. 

^  Miiller  (On  Cancer,  p.  153)  describes  one  between  the  optic  nerves  and  corpora  albi- 
cantia  ;  and  Roldtansky'(B.  i,  p.  282),  including  both  the  tumors  and  the  outgrowths,  refers 
to  examples  of  Lipoma  in  the  submucous  tissue  of  the  stomach,  intestines,  and  bronchi;  in 
the  subserous  tissue  of  the  pleura,  peritoneum,  dura  mater,  and  cerebral  ventricles;  and   in 


FATTY    TUMORS.  399 

locality  of  fat  rather  than  another.  Their  rarity  in  the  human  mesen- 
tery and-  omentum,  and  the  fat  about  the  internal  organs,  is  remarkable. 
I  have  never  seen  one  in  the  recent  state  in  any  of  these  parts ;  and  I 
know  only  two  or  three  specimens  in  museums.*  In  the  College  Mu- 
seum (No.  194)  is  a  bilobed  mass  of  fat,  inclosed  in  a  thick  capsule, 
and  attached  by  a  long  pedicle  to  the  intestine  of  an  ox.  In  the  trunk 
and  limbs,  they  appear  less  frequent  in  the  parts  in  which  the  natural 
fat,  though  abundant,  is  subject  to  least  variations  in  its  quantity  ;  such 
as  the  palms  and  soles,t  and  the  bones ;  and  they  are  rarely,  if  ever, 
formed  in  parts  of  or  near  the  trunk  where  very  little  fat  naturally 
exists,  as  the  eyelids|  and  the  greater  part  of  the  scrotum.  Fatty 
tumors  have,  indeed,  been  found  in  the  scrotum  ;  §  and  one  very  re- 
markable case  is  related  by  Mr.  Lawrence  and  Sir  B.  C.  Brodie :  but, 
perhaps,  such  tumors  have  not  begun  to  grow  in  the  part  in  which  they 
were  at  length  found ;  they  may  have  grown  or  shifted  into  it. 

This  shifting  of  fatty  tumors  is  worth  notice  ;  for  the  fact  may  be 
used  in  the  diagnosis  of  them  when  they  occur  in  the  groin  or  scrotum, 
or  other  unusual  place. 

A  patient  was  under  Mr.  Lloyd's  care,  in  St.  Bartholomew's  Hos- 
pital, with  a  strange-looking  pendulous  fatty  tumor  in  the  perineum. 
It  hung  like  a  pocket-flask  between  his  scrotum  and  thigh ;  but  he  was 
quite  clear  that  it  was  in  his  groin  ten  years  before,  and  that  it  had 
gradually  shifted  downwards.  It  was  removed,  and  no  pedicle  or  other 
trace  of  it  remained  in  the  groin. 

I  find,  also,  a  case  by  Mr.  Lyford,||  in  which  a  large  fatty  tumor  be- 
gan to  grow  in  the  abdominal  wall,  midway  between  the  spine  of  the 
ilium  and  the  pubes,  and  thence,  as  it  increased,  gradually  moved  down- 
wards, and  was  excised  from  the  upper  and  inner  part  of  the  thigh. 
And  thus,  in  Mr.  Lawrence's  case,  the  tumor  began  to  grow  in  the 

the  lungs,  liver,  and  kidneys.  A  very  remarkable  case  of  pendulous  fatty  tumor  of  the 
pharynx  and  larynx  is  related  by  Mr.  Holt.     Trans.  Pathol.  Soc,  vol.  v,  p.  123. 

*  One,  referred  to  in  Lecture  xxi,  is  in  the  Museum  of  St.  George's  Hospital.  Other 
cases  are  related  by  Vogel  (Path.  Anat.,  tab.  xxii.  Fig.  1}  ;  GJuge  (1.  c.  Lief,  viii)  ;  Lebert 
(Phys.  Pathol.,  ii,  p.  105).  They  are  not  rare  in  the  corresponding  parts  of  horses  and  other 
domestic  mammalia.  (Fiirstenburg  :  Die  Fettgeschwiilste  und  ihrer  Metamorphose;  Berlin, 
1851.)  The  editor  found,  on  one  occasion,  a  well-marked  fatty  tumor,  the  size  of  a  large 
walnut,  growing  in  the  submucous  tissue  of  the  large  intestine,  and  projecting  into  the  cavity 
of  the  gut  at  the  angle  of  junction  of  the  two  segments  of  the  ileo-ccecal  valve,  which  were, 
in  consequence,  much  displaced. 

f  M.  Follin  has  related  (C.  R.  de  la  Soc.  de  Biologie,  t.  iv,  p.  71)  a  case  of  a  fatty  tumor 
as  large  as  a  pullet's  egg  on  the  anterior  and  external  aspect  of  the  middle  finger  of  a  man 
about  fifty  years  old.  It  adhered  firmly  to  the  sheath  of  the  tendon,  which  was  opened  in 
removing  it.  In  the  St.  Bartholomews  Hospital  Museum  there  is  now  a  specimen  of  a  fatty 
tumor  from  the  palm. 

J  Cases  of  fatty  tumors  in  or  encroaching  on  the  orbit,  are  recorded  by  Mr.  Hutchinson 
in  the  Med.  Times  and  Gaz.,  December  16,  1853. 

§  Gluge  mentions  one  in  the  labium  of  a  woman  seventy  years  old.  It  was  pyriform,  and 
looked  like  a  hernia  (Path.  Anat.,  Lief,  viii,  Taf.  i,  Fig.   1). 

II  Med.  Gaz.,  iv,  348. 


400  FATTY    TUMORS. 

spermatic  cord,  and  thence  had  partly  extended  and  partly  shifted  into 
the  scrotum  behind  the  testicle,  where  it  was  extremely  difficult  to  de- 
cide its  nature.  For  in  the  layer  of  fat  outside  the  peritoneum  small 
fatty  tumors  (hernie  graisseuse)  not  unfrequently  grow,  which  may  ex- 
tend along  with  the  cord,  down  the  inguinal  canal,  and  in  their  position, 
at  least,  simulate  that  of  an  inguinal  hernia. 

The  fatty  tumors  usually  lie  in  the  subcutaneous  tissue,  extending  in 
it  between  the  skin  and  the  deeper  fascia :  but  they  may  extend  more 
deeply.  Mr.  Wormald  removed  one,  from  which  distinct  lobes  or  pro- 
longations passed  between  the  fasciculi  of  the  trapezius  muscle,  and, 
expanding  below  them,  were  constricted  by  them.  In  the  case  of  a 
great  fatty^  tumor*  of  the  neck,  removed  by  Mr.  Liston,  the  operation 
was  made  formidable  by  the  lobes  of  fat  extending  deeply  to  the  trachea 
and  oesophagus.  In  rare  cases,  fatty  tumors  may  be  altogether  deeply 
seated:  I  found  one  resting  on  the  lesser  trochanter  of  the  femur,  grow- 
ing up  by  the  side  of  the  pectineus  muscle,  but  not  prominent  externally. 
Vogel  mentions  the  case  of  a  woman  who  had  several  fatty  tumors,  one 
of  which  was  so  closely  connected  with  the  nasal  bone  and  the  nasal 
process  of  the  superior  maxillary  bone,  that  it  was  necessary  to  remove 
these  with  it.  Mr.  Abernethy  also  refers  to  a  fatty  tumor,  removed 
by  Mr.  Cline,  which  adhered  to  the  capsule  of  the  hip  joint.f  In  the 
Museum  of  the  Middlesex  Hospital  is  a  fatty  tumor  one  and  a  half 
inches  long,  which  was  removed  from  beneath  the  tongue,  where  it 
looked  like  a  ranula ;  in  the  College  Museum|  is  one  taken  from  the 
substance  of  the  tongue ;  and  Virchow  has  related§  a  case  of  numerous 
fatty  tumors  occurring  in  the  nerves  and  other  parts. 

Such  are  some  of  the  chief  facts  respecting  the  structure  of  this  kind 
of  tumors.     Of  their  life,  I  need  say  little. 

Their  development  is,  probably,  like  that  of  the  natural  fat,  and  in 
them,  according  to  C.  0.  Weber, ||  the  gradual  production  of  fat-cells 
out  of  connective-tissue  corpuscles  may  be  traced. 

Their  growth  is  usually  slow,  and  without  pain  or  any  aifection  of 
the  adjacent  parts  ;  but  they  often  grow  capriciously,  having  uncertain 
periods  of  acceleration  and  arrest,  of  which  no  explanation  can  be  given. 
The  extent  of  growth  cannot  well  be  measured ;  for  fatty  tumors  have 
been  cut  out  that  weighed  between  fifty  and  sixty  pounds,  and  such  as 
these,  after  twenty,  or  even  fifty  years,  were  still  growing,  and  might 
have  continued  to  do  so  as  long  as  the  patient  lived.  I  believe  the 
largest  in  London  is  that  in  the  Museum  of  St.  Thomas's  Hospital, 
which  was  removed  from  a  man's  abdomen  by  Sir  Astley  Cooper,  and 
weighed  37  lbs.  10  oz.^f  One  of  the  most  formidable  is  that  in  the  Col- 
lege Museum,  removed  by  Mr.  Liston  from  a  man's  neck,**  where  it  had 

*  Mus.  Coll.  Snrg.,  No.  190. 

t  See  also  Brodie,  1.  c. ;  Simon,  Lectures  on  Pathology;  and  others, 
f  No.  1065.  §  Archiv,  B.  xi,  H.  iii,  p.  281,  1857. 

II  Virchow's  Archiv,  B.  xv,  p.  61,  1859.      ^  Medico-Chirurg.  Trans.,  vol.  ix,  p.  440. 
**  No.  190. 


FATTY    TUMORS.  401 

been  growing  for  twenty-two  years.  A  parallel  to  it  is  drawn  in  the 
splendid  work  of  Auvert.* 

What  degenerations  the  fatty  tumors  may  be  liable  to  are  not  known ; 
their  diseases  have  some  points  of  interest. 

They  may  be  partially  indurated.  The  chief  mass  of  a  tumor  may 
be  found  with  the  characteristic  softness,  pliancy,  and  inelasticity  of 
fat ;  but  in  its  substance  one  or  more  lumps,  like  hard  knots,  may  be 
imbedded.  So  far  as  I  have  seen,  these  depend  on  induration,  contrac- 
tion, and  a  proportionate  increase,  of  the  connective  tissue  of  the  fat ; 
and  the  change  is  probably  due  to  slow  inflammation  of  the  tumor.  It 
may  be  sometimes  traced  to  frequent  pressure.  A  laundress  had  a  fatty 
tumor,  as  large  as  a  foetal  head,  above  her  ilium,  and  portions  of  it  were 
as  hard  to  the  touch  as  cartilage,  and  appeared  to  move  so  freely  in  the 
soft  fat-tissue  about  them,  one  might  have  thought  them  loose  bodies, 
or  fluid  within  cysts.  Where  these  were,  the  patient  had  been  in  the 
habit  of  resting  her  linen  basket. 

The  indurated  parts  of  a  fatty  tumor  may  be  the  seats  of  bone-like 
formations.  This  is,  I  believe,  very  rare ;  and  I  have  seen  only  the 
single  specimen  in  the  Museum  of  St.  Bartholomew's  Hospital  rf  but 
Auvert  describes  the  same  change. | 

Cysts,  also,  may  form  in  fatty  tumors.  In  the  case  with  partial  in- 
durations just  mentioned,  I  found,  in  another  part  of  the  tumor,  a  cyst 
with  thin  and  partially  calcified  walls,  which  contained  a  glutinous  and 
greenish  oily  fluid.  I  presume  it  is  to  tumors  of  this  kind  that  Gluge 
gives  the  name  of  Lipoma  colloides. 

Suppuration  and  sloughing  may  occur  in  these  tumors :  but  they  are 
on  the  whole  very  rare  events,  except  in  large  pendulous  tumors,  which 
have  grown  too  large  to  be  efi'ectively  nourished  through  their  bases  of 
attachment.  Pathologically  these  changes  have  little  interest ;  but  in 
practice  they  are  more  important,  as  being  almost  the  only  way  in  which 
external  fatty  tumors  are  likely  to  lead  to  death.  Even  in  these  cases, 
however,  they  show  no  real  imitation  of  malignant  disease. §  I  once, 
indeed,  saw  a  case  in  which  the  end  of  a  pendulous  fatty  tumor  in  a 
woman's  perineum  was  so  ulcerated  that  it  looked  like  cancerous  dis- 
ease :  but  after  a  week's  rest  in  bed,  during  which  the  patient  menstru- 
ated, it  lost  its  malignant  aspect.  It  now  acquired  (what  the  ulcers 
over  and  in  fatty  tumors  commonly  present)  clean,  inverted  and  over- 
hanging, wedge-shaped,  granulating  edges. 

*  Obs.  Med.-Chir  ,  Tab.  li.  See  for  a  list  of  the  largest  elsewhere  recorded,  Mr.  South's 
edition  of  Chelius's  Surgery,  ii,  pp.  691-2.  In  the  Cleveland  (U.  S.)  Medical  Gazette,  Au- 
gust, 1859,  is  an  account  of  a  "  Mammoth  Tumor"  of  the  abdomen  and  hip  by  Dr.  Delama- 
ter.     It  appears  to  have  been  composed  chiefly  of  fat,  and  w^as  estimated  at  275  lbs.  weight. 

f  Ser.  XXXV,  11. 

X  Tab.  xvi.     A  case  also  by  Mr.  T.  Smith  in  the  Trans.  Pathol.  Soc,  vol.  ix,  p.  384. 

§  On  the  possible  conjunction  of  fatty  tumors  and  malignant  disease,  see  Sir  B.  C.  Bro- 
die's  Lectures,  p.  282  ;  and  the  same  on  the  combination  of  fatty  and  mammary  glandular 
tumors. 


402  PIBRO-CELLULAR    TUM.ORS. 

Lastly,  respecting  the  causes  of  these  tumors  few  things  can  be  more 
obscure.  Nearly  all  knowledge  on  this  point  is  negative.  The  growth 
may  have  followed  an  injury,  and  we  may  call  this  the  cause  of  its  for- 
mation ;  but  we  can  give  no  explanation  why  such  an  event  as  an  injury, 
which  usually  produces  only  a  transitory  impairment  of  nutrition,  or  a 
trivial  inflammation,  should,  in  these  cases,  give  rise  to  the  production 
of  a  new  and  constantly  growing  mass  of  fat. 

FiBRO-CBLLULAR    TuMORS. 

Under  this  name  I  propose  to  consider  the  tumors  which,  in  their 
minute  structure  and  their  general  aspect,  resemble  the  fibro-cellular, 
areolar,  or  looser  form  of  connective  tissue  of  the  body.  So  far  as  I 
know,  no  general  account  of  them  is  published.  The  first  distinction  of 
them  was  made,  I  believe,  by  Mr.  Lawrence,*  who  described  an  admi- 
rable example  in  his  paper  on  Tumors :  and  they  are  briefly  but  accu- 
rately described  by  Mr.  Caesar  Hawkins,t  as  a  softer  and  more  elastic 
form  of  the  fibrous  tumor.  Muller,|  also,  refers  to  them  by  the  name  of 
Cellulo-fibrous  tumor  ;  Vogel,§  by  that  of  Connective  tissue  tumor 
(Bindegewebgeschwulste),  comparing  their  tissue  with  that  of  the  cutis; 
and  Kokitanskyll  points  to  them  as  a  variety  of  "gelatinous  sarcoma." 
But  these  passing  references  have  not  obtained  for  this  kind  of  tumor  a 
general  recognition,  and  in  many  works  it  is  altogether  overlooked. 

As  in  the  last  kind,  so  in  this,  we  find  instances  of  both  outgrowths 
and  tumors  ;  i.  e.  of  both  continuous  and  discontinuous  overgrowths. 
The  former  are,  indeed,  abundant  and  often  described  ;  for  among  them, 
as  being  formed  chiefly  of  overgrowing  fibro-cellular  tissue,  are  the 
most  frequent  forms  of  polypi  of  mucous  membranes,  and  of  hypertro- 
phies of  skin  or  cutaneous  outgrowths. 

1.  Nearly  all  the  softer  kinds  of  IPOLYPI,  growing  from  mucous  mem- 
branes,   consist   of   rudimental   or  more   nearly  perfect  fibro-cellular 

*  Medico-Chirurg.  Trans.,  vol.  xvii,  p.  14.         t  Medical  Gazette,  vol.  xxi,  p.  925. 

%  On  Cancer,  p.  14.  §  Pathologische  Anatomie,  p.  185. 

11  Path.  Anat.,  i,  p.  336.  Milller  and  others  describe,  under  the  name  of"  Collonema,"  a 
tumor  such  as  I  have  not  seen  unless  it  be  an  example  of  very  soft  fibro-cellular  tumor. 
Rokitansky  (i,  335)  describes  it  as  a  very  soft,  tolerably  clear,  flickering  substance,  like  gela- 
tine, of  grayish-yellow  color.  He  briefly  describes  four  specimens  observed  by  himself 
Bruch  describes  as  a  genuine  example  of  Collonema  vi^hat  I  can  scarcely  doubt  was  a  very 
soft  fibro-cellular  tumor.  (Ueber  Carcinoma  alveolare ;  in  Henle  and  Pfeufer"s  Zeitschrift, 
1849,  p.  356.)  A  description  of  Collonema  by  Wagner  (Virchow's  Archiv,  viii,  p.  232)  con- 
firms this  opinion.  Virchow,  also,  regards  these  cases  of  Collonema  as  nothing  more  than 
tumors  formed  of  very  soft  connective  tissue  soaked  in  an  albuminous  fluid  (Cellular  Patho- 
logic, Lecture  XX) ;  and  Billroth  (Entwick.  der  Blutgefasse,  p.  44),  states  that  a  Collonema 
is  a  connective  tissue  tumor  of  a  gelatinous  consistence,  the  fibres  of  which  are  of  extreme 
delicacy.  Virchow  has  also  described  under  the  name  of  Schleim-geschwtilste,  Myxomata, 
mucous  tumors,  a  set  of  tumors  which  correspond  in  their  structure  to  that  most  delicate  of 
all  the  forms  of  connective  tissue,  which  constitutes  the  tissue  of  the  vitreous  body,  Whar- 
tonian  jelly  of  the  umbilical  cord,  and  the  subcutaneous  tissue  of  the  embryo,  and  which  he 
names  mucous  tissue.  / 


FIBRO-CELLULAR    POLYPI.  403 

tissue,  made  succulent  by  serous  or  synovia-like  fluid  infiltrated  in  its 
meshes  :  the  firmer  kinds  of  polypi  are  formed  of  a  tougher,  more  com- 
pact, drier,  and  more  fibrous  or  fascia-like  tissue.  Of  the  softer  kind, 
the  best  examples  are  the  common  polypi  of  the  nose  :  mucous,  gela- 
tinous, or  vesicular  polypi,  as  they  have  been  called.  These  are  pale, 
pellucid,  or  opaque-whitish,  pendulous  outgrowths  of  the  mucous  mem- 
brane of  the  nose, — most  frequently  of  that  which  covers  the  middle  of 
its  outer  wall.  They  are  soft  and  easily  crushed,  and  in  their  growth 
they  adapt  themselves  to  the  shape  of  the  nasal  cavity,  or,  when  of 
large  size,  project  beyond  it  into  the  pharynx,  or,  more  rarely,  dilate 
it.  As  they  increase  in  size,  so,  in  general,  does  the  part  by  which 
they  are  continuous  with  the  natural  or  slightly  thickened  membrane 
become  comparatively  thinner,  or  flatter :  their  surfaces  may  be  simple 
and  smooth,  or  lobed ;  they  often  hang  in  clusters,  and  thus  make  up 
a  great  mass,  though  none  of  them  singly  may  be  large.  A  clear  ropy 
fluid  is  difiused  through  the  substance  of  such  polypi,  and  the  quantity 
of  this  fluid,  which  is  generally  enough  to  make  them  soft  and  hyaline, 
appears  to  be  increased  when  evaporation  is  hindered ;  for  in  damp 
weather  the  polypi  are  always  larger.  Bloodvessels  enter  their  bases, 
and  ramify  with  wide-extending  branches  through  their  substance, 
accompanying  usually  the  larger  and  more  opaque  bundles  of  fibro- 
cellular  tissue.  Cysts  full  of  synovia-like  fluid  sometimes  exist  within 
them. 

To  the  microscopic  examination  these  polypi  present  delicate  fibro- 
cellular  tissue,  in  fine  undulating  and  interlacing  bundles  of  filaments. 
In  the  interstitial  liquid  or  half-liquid  substance,  nucleated  cells  ap- 
pear, imbedded  in  a  clear  or  dimly  granular  substance ;  and  these  cells 
may  be  spherical,  or  elongated,  or  stellate ;  imitating  all  the  forms  of 
such  as  occur  in  the  natural  embryonic  fibro-cellular  tissue  :  or,  the 
mass  may  be  more  completely  formed  of  fibro-cellular  tissue,  in  which, 
on  adding  acetic  acid,  abundant  nuclei  appear.  In  general,  the  firmer 
the  polypus  is,  the  more  perfect,  as  well  as  the  more  abundant,  is  the 
fibro-cellular  tissue.  The  surface  is  covered  with  ciliary  epithelium 
exactly  similar  to  that  which  invests  the  healthy  nasal  mucous  mem- 
brane, and  supplies  the  most  convenient  specimens  for  the  examination 
of  active  ciliary  movement  in  human  tissues.* 

The  soft  polypi  that  grow,  very   rarely,  in  the  antrum,  and  other 

*  An  excellent  essay  on  the  structure  of  mucous  polypi  "  Ueber  den  Bau  der  Schleim- 
polypen"  has  been  published  by  Dr.  Th.  Billroth,  Berlin,  1855,  from  which  the  above 
description  of  the  structure  of  the  nasal  polypi  may  be  supplemented  with  a  few  additional 
particulars.  He  states  that  on  one  occasion  he  has  seen  nerve-fibres  in  a  nasal  mucous 
polypus,  but  their  mode  of  termination  he  could  not  determine.  He  has  also  found,  as 
might  naturally  be  expected,  the  mucous  membrane  on  the  surface  of  these  polypi  to  be 
glandular;  but  in  addition,  especially  in  the  larger  polypi,  he  has  observed  the  substance 
of  the  polypus  to  a  great  extent  made  up  of  gland  structures,  generally  like  the  natural 
glands  of  the  nasal  mucous  membrane,  but  sometimes  modified  in  shape. 


404  FIBKO-CELLULAR    POLYPI. 

cavities  communicating  with  the  nose,  are,  I  believe,  just  like  these.* 
And  those  of  the  external  auditory  passage  are,  in  structure,  not  essen- 
tially different.  All  that  I  have  been  able  to  examine  appeared  com- 
posed of  rudimental  fibro-cellular  tissue  ;f  but  they  are  generally  more 
vascular,  firmer,  and  less  succulent  than  the  nasal  mucous  polypi ;  they 
are  also  much  more  prone  to  inflammation  and  to  superficial  ulceration, 
perhaps  through  being  so  often  connected  with  disease  of  the  tympanum 
or  its  membrane.  The  mucous  polypi  of  the  uterus  are  also,  I  believe, 
like  those  of  the  nose. 

A  large,  deeply  lobed,  soft,  and  nearly  clear  polypus  in  the  urinary 
bladder,  the  only  specimen  I  have  seen  in  the  recent  state,|  was  com- 
posed, in  part,  of  very  fine  filamentous  fibro-cellular  tissue,  and,  in 
greater  part,  of  granular  or  dim  homogeneous  substance,  with  imbedded 
nuclei.  Over  the  substance  which  these  formed,  there  was  an  immense 
quantity  of  tessellated  epithelium,  with  large  scales,  like  those  of  the 
epithelium  of  the  mouth :  indeed,  so  abundant  was  this,  that  it  formed 
the  chief  constituent  of  the  smaller  lobes  of  the  polypus.  Once,  also, 
I  have  been  able  to  examine  a  polypus  of  the  rectum,  which,  being  soft 
and  succulent,  might  have  been  classed  with  these  ;  but  it  was  composed 
almost  entirely  of  gland-textures.  It  was  like  a  disorderly  mass  of 
such  tubular  glands,  lined  with  cylindriform  epithelium,  as  are  found 
in  the  mucous  membrane  of  the  rectum.  These  were  heaped  together 
with  some  intersecting  fibro-cellular  tissue,  and  with  abundant  viscid 
fluid-like  synovia  or  thin  mucus.  The  polypus  was  spheroidal,  about 
two-thirds  of  an  inch  in  diameter,  and  attached  by  a  pedicle  nearly  an 
inch  long  to  the  anterior  wall  of  the  rectum  :  it  received  so  abundant  a 
supply  of  blood  through  the  pedicle,  that  I  think  excision  would  have 
been  very  unsafe,  unless  I  had  first  tied  the  base  of  the  pedicle.  § 

*  See  Schuh,  Pseudoplasmen,  p.  75.  Billroth  (p.  14)  describes  and  figures  a  good  in- 
stance of  polypus  of  the  antrum,  which  he  considers  to  be  a  very  rare  affection.  But 
Luschka  (Virchow's  Archiv,  B.  iv,  p.  419,  1855),  states  that  these  polypi  are  not  so  rare  as 
is  usually  supposed.  He  has  found  them  five  times  in  about  sixty  bodies  examined.  He 
considers  them  to  be  hypertrophies  of  the  submucous  connective  tissue  covered  with  the 
mucous  membrane.  Forster  has  given  beautiful  figures  illustrating  the  structure  of  a  poly- 
pus from  the  antrum,  in  pi.  25  of  his  Atlas. 

f  M.  Lebert  says  the  specimens  he  has  observed  were  composed  of  fibro-plastic  tissue. 
Professor  Baum  tells  me  he  has  generally  found  the  surfaces  of  aural  as  well  as  of  nasal 
polypi  covered  with  ciliary  epithelium.  Meissner,  Billroth,  Forster,  and  the  editor,  have 
also  seen  ciliated  epithelium  on  the  surface  of  aural  polypi,  and  both  Billroth  and  Forster 
(Atlas,  Taf.  xxxv),  have  found  distinct  and  tolerably  large  papillse  on  them. 

X  It  is  in  the  Museum  of  St.  Bartholomew's,  and  is  described  by  Mr.  Savory  in  the  Medi- 
cal Times,  July  31,  1852.  Mr.  Birkett  has,  in  Trans.  Med.  Chi.  Soc,  vol.  xli,  1858,  described 
a  polypus  of  the  bladder  which  "  resembled  in  every  anatomical  particular  the  succulent 
fibrous  growth  termed  nasal  polypus." 

§  Other  cases  of  mucous  and  glandular  polypi  of  the  rectum  may  be  found  recorded  by 
M.  Forget  in  the  Union  Medicale,  June  21,  1853  :  by  Harpeck  in  a  pamphlet  "De  polypis 
recti,"  1855;  by  Forster  in  his  Atlas,  Taf  xxv,  and  by  Billroth  in  the  essay  already  quoted. 
The  last-named  observer  has  also  described  cases  of  mucous  polypi  of  the  larynx  and  tra- 
chea, of  the  female  urethra  and  of  the  uterus.  He  refers  also  to  two  cases  of  mucous  polypus 
of  the  lacrymal  sao. 


CUTANEOUS  OUTGROWTHS.  405 

2.  The  best  examples  of  Cutaneous  Outgrowths,  of  which,  as  I 
have  said,  a  second  division  of  the  fibro-cellular  outgrowths  is  com- 
posed, are  those  which  occur  in  the  scrotum,  prepuce,  labia,  nymphge, 
clitoris  and  its  prepuce,*  These,  which  reach  their  maximum  of  growth 
in  the  huge  "elephantiasis  scroti"  of  tropical  countries,  consist  mainly 
of  overgrowing  fibro-cellular  tissue,  which,  mingled  with  elastic  tissue, 
and  with  more  or  less  fat,  imitates  in  general  structure  the  outer  com- 
pact layer  of  the  cutis.  Their  tissue  is  always  closely  woven,  very 
tough,  and  elastic  ;  in  some  cases  it  is  compressible  and  succulent,  as 
if  anasarcous,  and  it  yields,  on  section,  a  large  quantity  of  serous-look- 
ing fluid  ;  in  others,  it  is  much  denser,  interlaced  with  strong,  shining 
bands,  like  those  of  a  fascia ;  in  others,  it  is  meshed  with  intervening 
lobes  of  fat ;  and  in  others,  is  uniformly  solid  and  glistening,  yellowish, 
or  with  an  ochre  tinge,  like  udder.  The  minute  textures  are,  however, 
I  believe,  essentially  the  same  among  these  diversities  of  general  aspect ; 
they  are,  in  various  proportions,  the  usual  textures  of  the  cutis  and  sub- 
cutaneous tissue,  excepting  (so  far  at  least  as  present  observation  ex- 
tends) the  smooth  muscular  fibres.  The  diversities  of  external  form 
are  more  numerous.  In  some,  as,  most  commonly,  on  the  nymphse  and 
prepuce  of  the  clitoris,  the  masses  are  suspended  by  comparatively 
narrow  pedicles ;  thus,  also,  are  suspended  most  of  the  small  cutaneous 
outgrowths  that  are  common  on  the  trunk  and  limbs  ;  in  some  the  bases 
are  very  broad,  as  in  the  nose,  in  which,  moreover,  the  growth  of  skin 
is  generally  associated  with  acne  and  dilatation  of  its  minute  blood- 
vessels ;  in  some,  as  in  the  elephantiasis  scroti,  a  large  extent  of  skin 
appears  uniformly  afiected.  Again,  in  difl"erent  instances,  they  are 
lobed,  or  less  deeply  subdivided,  or  smooth  or  warty  on  their  surfaces  ; 
healthy  or  darkened  epidermis  covers  them ;  and  the  sebaceous  glands 
and  hair-follicles  sinking  beneath  their  surfaces,  as  in  the  healthy  skin, 
are  not  unfrequently  considerably  enlarged.  In  the  elephantiasis  of 
the  extremities  and  of  the  scrotum,  not  only  the  isolation,  but  even  the 
circumscribed  appearance,  of  a  tumor  is  lost ;  the  affection  is  classed 
with  the  diseases  of  the  skin  rather  than  with  tumors,  and,  in  morbid 
anatomy,  is,  perhaps,  not  to  be  distinguished  from  the  consequences  of 
chronic  or  repeated  inflammations  of  the  integuments.  In  all  cases, 
however,  let  the  external  form  be  what  it  may,  there  is  such  uninter- 
rupted continuity  between  the  several  tissues  of  the  overgrowth  and 

Polypi  of  the  vagina  should  also  be  classed  along  with  the  above,  as  examples  of  mucous 
polypi.  Sir  C.  Locock  has  stated  that  he  had  often  seen  a  single  little  mucous  polypus  at- 
tached to  a  nyrapha,  or  some  part  of  the  v^all  of  the  vagina  in  children,  either  at  birth,  or 
in  later  life. 

*  I  suppose  that  the  disease  named  Molluscum  simplex  should  be  classed  with  these  ;  but 
I  have  never  seen  a  good  instance  of  it.  The  best  accounts  that  I  have  read  are  by  G. 
Simon:  "Die  Hautkrankheiten,"  pp.  .50  and  219,  and  Jacobovics  ;  Du  Molluscum.  Another 
form  of  disease  sometimes  thus  named  consists  in  morbid  changes  of  very  numerous  hair- 
follicles.     See  a  case  by  Dr.  Beale  in  Trans.  Pathol.  Soc,  vi,  313. 


406  '  FIBRO-CELLULAR    TUMORS. 

those  of  the  healthy  cutis,  that  the  disease  might  be  taken  as  the  type 
of  the  "continuous  overgrowths."* 

FiBRO-CELLULAR  TuMORS,  properly  so  called,  are  much  rarer  than 
the  outgrowths  of  the  same  texture  which  I  have  just  described.  They 
are  also  rare  in  comparison  with  other  tumors  ;  and  this  is  singular, 
considering  the  abundance  of  the  fibro-cellular  tissue  naturally  existing, 
its  general  diffusion,  its  easy  formation  after  injuries,  in  disease,  and 
even  in  and  about  other  tumors.  I  can  in  no  wise  explain  the  fact ;  but 
it  is  certain  that  for  ten  tumors  formed  of  fat  or  cartilage  (tissues  which 
are  rarely  produced  in  other  diseases),  we  do  not  find  more  than  one 
formed  of  fibro-cellular  tissue. 

The  form  in  which  the  fibro-cellular  tumors  are  most  frequently  seen 
is  that  of  oval  or  round  masses  of  soft,  elastic,  close,  and  pliant  tissues, 
smooth  and  uniform,  or,  when  they  grow  among  yielding  parts,  deeply 
and  variously  lobed.  Their  exterior  surface  is  connected  with  the  ad- 
jacent parts  by  a  capsule  of  connective  tissue,  which  generally  splits 
readily.  When  handled  they  feel  peculiarly  tense  and  elastic ;  their 
outer  surface  may  shine  like  a  thin  sac  full  of  fluid.  On  their  sections 
we  see  opaque  white  bands,  intersecting  a  shining  succulent  basis-sub- 
stance of  serous  yellow  or  greenish  yellow  tint.  Through  this  basis 
the  bands  course  in  circles  or  wavy  lines,  or  form  complete  partitions ; 
or,  in  the  smaller  lobes  of  the  tumor,  they  run  without  order,  only 
forming  white  marks  on  the  yellow  ground-color,  but  giving  no  appear- 
ance of  grain,  or  of  regularly  fibrous  structure. 

The  peculiar  yellow  color  of  the  basis-substance  of  these  tumors 
makes  them  look  at  first  like  fat ;  it  is  due,  however,  not  to  fat,  but  to 
a  serous,  or  synovia-like,  or  very  viscid,  fluid,  which  is  infiltrated  through 
the  substance  of  the  tumor.  The  mass  is  just  like  anasarcous  areolar 
tissue ;  most  of  all  like  the  subcutaneous  areolar  tissue  of  the  back,  as 
one  sees  it  dissected  in  a  dropsical  body.  When  such  a  tumor  is  cut 
through  or  sliced,  the  clear  yellow  fluid  oozes  from  it,  or  may  be  abun- 

*  Well-marked  specimens  of  cutaneous  outgrowths  are  in  the  Museum  of  the  College, 
Nos.  2283  to  2290,  2466-7,  2708  to  2714  ;  and  in  that  of  St.  Bartholomew's,  Ser.  xi,  18,  19  ; 
Ser.  xxviii,  18;  and  Ser.  xxxii,  36,  37.  I  lately  cut  one  from  a  man's  nates  (a  very  un- 
usual place  of  growth),  which  weighed  upwards  of  eight  pounds.  It  had  been  growing 
for  twenty  years,  and  formed  a  great  pendulous  mass,  on  which  he  used  to  sit :  its  base 
covered  the  whole  region  of  the  glutei  muscles.  As  examples  of  cutaneous  outgrowths, 
ought  also  to  be  enumerated  those  cases  of  a  peculiar  form  of  tumor  of  the  skin  which  Pro- 
fessor Valentine  Mott  has  described  by  the  name  of  "  Pachydermatocele"  in  the  Med.  Chi. 
Trans.,  vol.  xxxvii,  1854.  Of  the  five  cases  recorded,  one  returned  twice  after  removal. 
Other  cases  of  cutaneous  outgrowths  are  recorded  by  Mr.  0.  Pemberton  in  Med.  Times  and 
Gaz.,  July,  1856. 

With  the  cutaneous  outgrowths  ought  perhaps  to  be  included  those  curious  cases  which 
constitute  the  Keloid  of  Alibert,  and  which  appear  to  consist  of  a  fibrous  development  in 
the  subcutaneous  areolar  tissue.  Fuller  information  on  this  subject  may  be  found  in  Die- 
berg's  pamphlet  "De  Tumoribus  Celoidibus,"  Dorpat,  1852,  and  in  a  paper  by  Dr.  Addison 
in  Trans.  Med.  Chi.  Soc,  vol.  xxxvii,  1854. 


FIBRO-CELLULAR    TUMORS.  407 

dantly  pressed  out ;  in  alcohol  the  same  fluid  coagulates  ;  in  both  cases, 
the  filamentous  tissue  contracting,  becomes  denser  and  more  compact, 
and  more  uniformly  opaque  white,  like  that  of  the  softer  varieties  of 
fibrous  tumor.  It  is  to  these  last-named  tumors,  indeed,  that  the 
fibro-cellular  have  the  nearest  relations,  and  into  them  that  they  "pass" 
through  gradational  specimens ;  but  there  is  just  the  same  diiference, 
as  well  as  just  the  same  relation,  between  these  kinds  of  tumors,  as  there 
is  between  the  natural  fibro-cellular  and  fibrous  tissues ;  and  there  is 
a  similar  propriety  in  distinguishing  them. 

Examined  with  the  microscope,  the  fibro-cellular  tumors  display  the 
filamentous  tissue  or  appearance  characteristic  of  that  after  which  they 
are  named.  In  many  cases,  or  in  many  parts,  parallel,  soft,  undula- 
ting   filaments    are 

found   collected   in  Fig.  52.* 

fasci(?uli,  which  in- 
terlace,   and    from 

which    single    fila-         •  M^'  i  _  ^' 

ments  can  often  be  ^'  jl:  % .  ^0^^"^" 

traced  out  (Fig.  52);  I     /f  I        /        Jfi  .-? 

or,   where    this    is  f    //i  I       /         J'^H/  /" 

not  seen,  the   tex-  I  '/ ?  '       i  9cWl  ./' 


-^ 


ture  looks  filament- 
ous, through  mark- 
ings or  wrinkles  of  ,,-^..,  v  /| 

the    surface    of    a       i\  /f       '0''    '"■v\"''\    \| 

more   homogeneous  ''-■        ,.■:/"     .--»j5^7-=^*iT"r.S!:kbs^'^ 

substance.  The 

best  developed  and 

most  filamentous  tissue  is  in  the  intersecting  white  bands :  but  similar 
tissue  is  usually  present  everywhere.  In  many  instances  abundant 
nuclei  appear  among  the  filaments,  or  imbedded  in  the  more  homoge- 
neous substance,  and  acetic  acid  rarely  fails  to  bring  into  view  such 
nuclei  in  crowds.  In  many,  also,  cells  like  those  of  granulations,  and 
others  elongated  and  attenuated,  appear  as  if  in  process  of  development 
into  filaments. 

The  homology  of  these  tumors,  in  respect  of  tissue,  is  thus  as  perfect 
as  that  of  the  fatty  tumors.  In  chemical  analysis  they  may  yield 
gelatine  from  the  well-formed  fibro-cellular  tissue ;  but  I  believe  they 
yield  much  more  albuminous  matter  from  their  imperfectly  developed 
tissue,  and  from  the  serous  fluid  that  is  soaked  in  them. 

In  general,  there  is  nearly  complete  uniformity  through  the  whole 
mass  of  one  of  these  tumors.  Oftentimes,  however,  different  portions 
are  more  or  less  oedematous  (if  I  may  so  call  them) ;  and,  which  is  more 

*  Microscopic  elements  of  a  fibro-cellular  tumor,  with  cells  in  various  stages  of  elongation 
and  attenuation.     Magnified  about  450  times. 


408 


FIBRO-CELLULAR    TUMORS. 


remarkable,  portions  of  cartilage,  sometimes  partially  ossified,  may  be 
found  in  or  over  tbem.     I  have  thrice  seen   this.     In  the  first  case 

nodules  of  cartilage  were  im- 
Fig.  53.*  bedded  in  a  fibro-cellular  tu- 

mor that  grew  in  the  ball  of 
the  great  toe ;  in  the  second 
(a  similar  tumor  from  the 
thigh)  (Fig.  53),  a  portion  of 
its  surface,  and  one  of  its  chief 
partitions,  were  formed  with 
cartilage  partially  ossified  ;  in 
the  third,  a  similar  tumor  from 
the  thigh  was  thinly,  but  com- 
pletely, encased  with  bone.f 
Moreover,  besides  these  «difi"er- 
ences  dependent  on  mixtures 
of  other  tissues  with  those 
proper  to  the  tumors,  some 
may  be  found  which  are  due 
to  parts  of  the  tumor  being  immature  or  imperfectly  developed,  and 
from  this  imperfect  state  degenerate.  I  have  lately  seen  two  such  spe- 
cimens, of  which  one  was  removed  from  the  inner  and  deeper  part  of  a 
gentleman's  ham  by  Mr.  Lawrence ;  and  the  other,  seated  between  the 
superficial  and  deep  muscles  of  a  woman's  fore-arm,  was  removed  by 
Mr.  Gay.  The  former  was  of  three  years',  the  latter  of  two  years', 
growth.  Both  were  of  oval  form,  deeply  lobed,  very  soft,  loosely  con- 
nected by  a  thin  capsule  with  the  adjacent  healthy  parts,  and  about 
eight  inches  in  chief  diameter.  Partitions,  proceeding  from  the  capsule, 
and  including  large  bloodvessels,  intersected  the  tumors,  which  were 
mainly  composed  of  a  bright  serous-yellow,  flickering,  but  tenacious 
substance,  half  pellucid,  like  size-gelatine.  Opaque  white  lines  travers- 
ing this  substance,  gave  it  the  general  appearance  of  the  softest  and  most 
succulent  fibro-cellular  tumors,  or  of  the  common  mucous  polypus  of  the 
nose. 

These  characters,  which  were  common  to  large  portions  of  both 
tumors,  were,  however,  in  some  lobes  of  each,  widely  deviated  from.  In 
the  tumor  from  the  ham,  some  lobes  were  sufi"used  and  traced  over  with 
bright  crimson  and  vermilion  tints,  and  looked  like  lumps  of  size  and 
vermilion  ill-mixed  for  an  injection.  Other  lobes  had  patches  of  buif- 
colored  or  ochrey  soft  shreddy  substance,  or  consisted  almost  wholly  of 
such  a  substance.  In  the  tumor  in  the  fore-arm  there  was  less  appear- 
ance of  vascularity,  but  the  ochrey  substance  was  more  abundant,  and 


*  Section  of  a  fibro-cellular  tnmor  intersected  with  cartilage  and  partially  encased  with 
bone:  reduced  one-half.     Described  above,  and  p.  413. 

t  All  these  specimens  are  in  the  Museum  of  St.  Bartholomew's  Hospital. 


FIBKO-CELLULAR    TUMORS.  409 

parts  of  some  lobes  seemed  liquefied  in  a  turbid  thick  fluid  of  ochre  or 
bufi"-yellow  tint.  In  other  portions  it  had  a  greenish-yellow  hue,  as  if 
infiltrated  with  dried-up  pus ;  in  others,  it  was  nearly  Avhite  and  brain- 
like ;  in  others,  it  had  mingled  shades  of  pink  and  gray.  But  various 
as  were  the  aspects  of  these  tumors,  so  that  with  the  naked  eye  it  would 
have  been  extremely  difficult  or  impossible  to  discern  their  kind,  yet, 
in  all  parts,  they  showed  microscopic  structures  characteristic  of  the 
fibro-cellular  tissue  in  an  immature  state.  Serous  or  synovia-like  fluid 
oozed  from  them,  but  none  that  was  pulpy  or  cream-like.  The  serous 
colored  parts  consisted  mainly  of  well-formed  fibro-cellular  tissue,  or  of 
a  clear  imperfectly  fibrillated  blastema,  with  closely  imbedded  corpus- 
cles, like  nuclei.  Many  of  these  corpuscles  were  clear,  but  many  were 
granular,  as  if  with  fatty  degeneration,  or  appeared  changed  into  small 
granule-masses.  In  the  bufl"  and  ochre-colored  parts,  similar  tissue  or 
blastema  was  sprinkled  over,  or  was  quite  obscured,  with  minute  shin- 
ing black-edged  molecules,  like  oil  particles,  and  with  drops  of  oil.  In 
other  parts,  some  nuclei  appeared  like  those  of  very  soft  cartilage ;  in 
others  crystals  of  cholesterine  were  mingled  with  the  oily  matter.  In 
the  greenish-yellow  parts,  also,  were  corpuscles,  like  shrivelled  pus-cells, 
mixed  with  fatty  particles  and  debris ;  and,  again,  in  other  parts,  cells 
elongated  like  those  of  granulations. 

No  specimens  could  illustrate  better  than  such  as  these  the  necessity 
of  learning,  as  I  have  already  said,  to  distinguish,  in  each  tumor,  the 
exceeding  varieties  presented  in  the  phases  of  development  of  prema- 
ture degeneration  and  of  disease. 

The  most  frequent  seats  of  fibro-cellular  tumors  appear  to  be  the 
scrotum,  the  labium  or  the  tissues  by  the  side  of  the  vagina,  and  the 
deep-seated  intermuscular  spaces  in  the  thigh  and  arm.  They  may 
occur,  probably,  in  many  other  parts;  but  either  they  particularly 
aff"ect  these,  or  else  a  singular  chance  has  shown  them  to  me  in  these 
situations  with  unusual  frequency. 

In  the  scrotum  I  have  been  able  to  examine  two  cases,  and  have 
found  records  or  notices  of  many  more.  The  first  case  is  represented 
in  a  large  specimen  in  the  Museum  of  St.  Bartholomew's,  and  in  a 
drawing  made  shortly  after  the  parts  were  removed.  The  patient  was 
a  carpenter,  74  years  old ;  and,  when  he  was  under  Mr.  Stanley's  care, 
the  tumor  had  existed  four  years.  It  was  a  huge  mass,  about  a  foot 
long,  and  six  or  seven  inches  wide,  filling  the  scrotum,  and  drawing  over 
it  all  the  adjacent  integuments.  A  collection  of  fluid,  like  a  hydrocele, 
was  at  its  lower  part,  a  large  hernial  sac  was  above  it,  and  the  scrotum 
was  thick  and  oedematous.  The  obscurities  these  complications  threw 
upon  the  diagnosis  of  the  tumor,  the  doubt  how  far  the  hernial  sac  might 
extend,  the  patient's  age,  and  his  aversion  from  any  operation,  were 
sufficient  to  dissuade  from  active  interference. 

The  patient  died  about  half  a  year  after  leaving  the  hospital.     The 

27 


410  FIBRO-CELLULAR    TUMORS. 

tumor  had  attained  the  weight  of  twenty-four  pounds ;  the  testicle,  with 
a  distended  tunica  vaginalis,  lay  pressed  down  below  it,  and  the  hernial 
sac  was  quite  clear  of  it  above.  It  was  easily  separable  from  the  sur- 
rounding tissues,  into  which  many  lobes  extended  far  from  the  chief 
mass,  and  on  section  appeared  partitioned  into  lobes  of  various  sizes 
and  shapes.  It  had  all  the  characters  which  I  have  described  as  be- 
longing generally  to  these  tumors,  varied  only  by  the  unequal  collec- 
tions of  blood  or  of  serum,  or  by  its  various  firmness  of  texture  in  its 
several  portions. 

A  similar  case  was  brought  to  St.  Bartholomew's  by  Mr.  C.  R. 
Thompson,  to  whom  I  am  indebted  for  the  history.  The  patient  was  a 
parish  clerk,  70  years  old,  a  sickly-looking  man,  and  the  tumor  had 
been  nine  years  in  progress  before  his  death.  It  was  first  noticed  as  a 
hardness  just  above  the  testicle;  but  as  it  constantly  increased  in  size, 
it  filled  the  whole  scrotum,  displacing  the  adjacent  integuments,  and 
looking  at  first  sight  like  an  enormous  hydrocele.  Its  surface  was 
uneven  and  lobed,  in  some  parts  feeling  hard  and  brawny,  in  some  soft 
and  fluctuating.  For  many  years  it  was  inconvenient  only  by  its  size 
and  weight;  but,  about  a  month  before  death,  one  of  its  prominent  parts 
sloughed,  and  hemorrhage  took  place  from  it.  After  this,  more  exten- 
sive sloughing  took  place,  and  more  considerable  hemorrhage,  and  the 
patient  sank. 

The  tumor  had  the  same  characters  as  the  last,  except  in  the  part 
that  was  sloughing,  which  was  denser  and  more  compact,  and  of  a  dark 
blood-stained  color,  like  congested  liver.  This  might  have  been  thought 
cancerous;  but  with  the  microscope  I  found  only  fibro-cellular  tissue 
infiltrated  with  inflammatory  exudation  and  blood ;  in  other  portions, 
unmixed  fibro-cellular  tissue.* 

To  these  cases  I  might  add  one  related  by  M.  Lesauvages,f  in  which 
the  tumor,  in  a  man  70  years  old,  weighed  at  least  44  pounds,  and  was 
of  such  size  that,  as  the  patient  sat  with  it  resting  on  his  thighs,  it 
reached  to  his  sternum  and  beyond  his  knees.  And  another  of  the 
same  kind  is  related  by  Dr.  O'Ferrall,  which  he  removed  successfully ; 
but,  excellent  as  the  surgery  of  this  case  was,  its  pathological  complete- 
ness is  marred  by  the  suspicion  that  a  small  portion  of  it  was  of  can- 
cerous structure,  and  by  the  finding  of  a  "  solitary,  hard,  circumscribed 
tuber"  in  the  patient's  liver,  when,  some  months  after  complete  reco- 
very from  the  operation,  he  died  with  phthisis.  J 

*  The  two  foregoing  cases  are  published  by  Mr.  Thompson  in  the  Medical  Gazette,  May 
30,  1851. 

■j-  Archives  G6n.  de  Med.,  t.  ix,  p.  212,  1845.  M.  Lesauvages  refers  to  another  very 
probable  case  in  which  Bayle  removed  the  tumor.  It  was  of  three  or  four  years'  growth, 
and  as  large  as  a  head.  The  patient  died,  without  return  of  the  disease,  seven  or  eight 
years  afterwards. 

J  I  am  indebted  for  these  particulars,  beyond  what  were  published  in  the  Dublin  .Tournal 
of  Medical  and  Chemical  Science,  vol.  i,  1846,  to  the  kindness  of  Dr.  O'Ferrall.  Mr.  Cur- 
ling (On  Diseases  of  the  Testis,  p.  51)  refers  to  two  cases  of  small  "  fibrous"  tumors  removed 


FIBRO-CELLULAR    TUMORS.  411 

Of  the  similar  tumors  growing  by  tlie  vagina,  the  best  instance  that 
I  know  is  that  recorded  by  Mr.  Lawrence.*  A  portion  of  the  tumor 
is  in  the  Museum  of  St.  Bartholomew's  Hospital ;  and,  though  altered 
from  its  first  condition,  it  proves  the  identity  of  the  disease  with  that 
of  which  I  have  been  speaking. 

The  patient  was  a  lady,  twenty-eight  years  old,  and  the  tumor,  sus- 
pended from  the  labium  and  buttock  as  far  as  the  coccyx,  reached  near 
to  her  knees,  was  as  broad  as  her  two  thighs,  and  measured  32  inches 
in  its  greatest  circumference.  It  had  been  growing  four  years,  and 
produced  no  inconvenience  except  by  its  weight  and  bulk.  It  was  soft 
and  lobed,  and  the  skin  was  loosely  connected  with  it.  Mr.  Lawrence 
removed  the  greater  part  of  this  tumor ;  but  a  portion  which  advanced 
into  the  labium  and  along  the  side  of  the  vagina  could  not  be  eradicated: 
this  was  therefore  cut  across ;  and,  when  it  had  grown  again,  was  re- 
moved in  a  second  operation  two  years  afterwards.  The  patient  then 
recovered  perfectly,  and  is  still  living,  without  any  return  of  the  dis- 
ease, more  than  twenty  years  after  the  operation.  Mr.  Lawrence's 
account  of  the  tumor,  and  its  present  appearance,  leave  no  doubt  that 
it  was  of  this  fibro-cellular  kind. 

A  similar  specimen,  weighing  more  than  10  pounds,  was  removed  by 
Mr.  Liston  from  a  patient  thirty  years  old,  in  whom  it  had  been  grow- 
ing many  years,  and  a  portion  of  it  is  in  the  Museum  of  the  College 
(No.  2715).  Many  of  smaller  size  have  been  removed  from  the  same 
part  ;f  and  I  have  met  with  two  which  have  presented  the  same  disease 
in  another  phase. 

A  woman,  thirty-four  years  old,  had  a  tumor  pendulous  from  the 
right  wall  of  the  vagina  and  the  right  nympha.  It  was  a  large  flask- 
shaped  mass,  about  five  inches  in  diameter,  attached  by  a  pedicle  about 
one  inch  and  a  half  in  length  and  thickness,  over  the  upper  part  of 
which  the  orifice  of  the  urethra  was  arched.  All  the  lower  part  of  the 
tumor  was  sloughing,  and  discharging  an  offensive  ichorous  fluid.  The 
upper  half  was  covered  with  healthy  mucous  membrane,  and  felt  uni- 
formly tough,  pliant,  and  elastic. 

The  patient  had  noticed  this  disease  for  three  or  four  years.  It 
began  as  a  tumor,  projecting  into  the  vagina  from  beneath  its  right 

from  the  scrotum,  in  one  of  which  the  tumor  was  supposed  to  be  a  third  testicle.  These 
were  probably  of  the  kind  here  described.  So,  probably,  were  those  referred  to  by  Schuh 
(Pseudoplasmen,  p.  69),  in  one  of  which  a  fatty  tumor  was  combined  with  one  of  several 
"  fibroid"  tumors  in  a  scrotum.  Other  cases  in  the  scrotum  are  also  described  by  Mr.  Hut- 
chinson in  the  Med.  Times  and  Gazette,  December  31,1853.  And  in  the  Lancet,  July, 
1856,  is  recorded  a  case  in  the  practice  of  Mr.  Fergusson  where  the  tumor  recurred  in  the 
scrotum. 

*  Medico-Chirurgical  Transactions,  vol.  xvii,  p.  11. 

f  Mr.  Lawrence,  1.  c,  refers  to  one  by  Mr.  Earle.  Cases  are  also  described  by  Sir  B.  C. 
Brodie,  Med.  Gaz.,  vol.  i,  p.  484;  Mr.  Ceesar  Hawkins,  Med.  Gaz.,  vol.  xxi,  p.  925;  Mr. 
Curling,  Proceedings  of  the  Pathological  Society,  Part  ii,  p.  301  ;  and  (probably)  by  Dr. 
O'Ferrall,  Dublin  Journal,  vol.  i,  p.  520,  and  vol.  iv,  p.  337.  A  specimen  from  a  case  by 
Mr.  Keate  is  in  the  Museum  of  St.  George's  Hospital. 


412  FIBRO-CELLULAR    TUMORS. 

wall,  and  in  this  situation  acquired  a  large  size  before  it  protruded  ex- 
ternally. It  was  punctured,  and  then  grew  more  rapidly  ;  but  the  pro- 
trusion did  not  take  place  till  about  ten  days  before  I  saw  the  patient. 
After  this  protrusion  it  enlarged  very  quickly,  and,  with  the  sloughing, 
the  general  health  suffered  severely.  I  removed  the  tumor  eighteen 
months  ago,  dissecting  it  out  with  little  difficulty,  and  the  patient,  I 
believe,  remains  well. 

It  presented  a  well-marked  instance  of  a  very  oedematous  and  slough- 
ing fibro-cellular  tumor,  and  microscopic  examination  found  abundant 
inflammatory  exudation  mingled  with  the  rudimental  fibro-celiular  tissue. 

At  nearly  the  same  time  I  saw  a  case  essentially  similar  to  this  ;  but 
the  tumor  was  suspended  from  the  labium,  and  the  patient  was  about 
sixty  years  old.  And  this  last  fact  is,  perhaps,  worth  notice ;  inasmuch 
as,  with  this  exception,  all  the  cases  of  the  fibro-cellular  tumor  by  the 
vagina  that  I  have  met  with  have  occurred  in  young  women,  while  all 
the  similar  tumors  in  the  scrotum  have  been  in  old  men. 

The  occurrence  of  such  tuinors  as  these  in  the  scrotum  and  labium 
may  make  it  necessary  that  I  should  particularly  say  they  are  not  the 
same  disease  as  are  the  cutaneous  growths  which  form  the  pendulous 
tumors — the  elephantiasis,  as  it  is  sometimes  called — of  the  same  parts, 
and  which  I  have  already  briefly  described.  The  main  differences  are : 
1st.  That  these  fibro-cellular  tumors  may  be  separated  or  enucleated 
from  the  tissues  among  which  they  lie ;  whereas  the  cutaneous  growths 
have  no  definite  boundary,  but  are  continuous  with  the  proper  tissue  of 
the  scrotum,  or  labium,  or  nympha :  the  two  diseases  have  the  common 
differences  between  tumors  and  outgrowths.  2d.  In  the  growth  of  the 
fibro-cellular  tumors,  the  surrounding  parts,  including  the  skin,  or  the 
mucous  membrane,  grow  in  adaptation  to  the  tumor,  but  often  defec- 
tively, or,  at  the  most,  only  normally  ;  but  in  the  cutaneous  outgrowths 
all  the  tissues  take  part,  and  the  proper  tissue  and  appended  organs 
of  the  cutis  are  nearly  as  much  exaggerated  as  the  fibro-cellular  sub- 
stance. And  3dly.  In  the  tumors,  fibro-cellular  tissue  is  the  highest 
form  attained,  or,  at  most,  a  small  quantity  of  elastic  tissue  is  mingled 
with  it ;  but,  in  the  outgrowths,  all  the  component  structures  of  the 
skin  and  subcutaneous  tissue  are  increased. 

The  two  diseases  are  thus  different-  Still,  the  fact  is  significant  that 
the  parts  most  liable  to  the  cutaneous  outgrowths  are  also  those  in  or 
near  which  the  fibro-cellular  tumors  most  frequently  occur  ;  and  it  may 
be  noted  that,  among  those  parts  in  which  fatty  tumors  are  most  rare, 
the  fibro-cellular  are  the  most  common. 

For  examples  of  fibro-cellular  tumors  removed  from  deep  intermus- 
cular spaces,  I  may  refer  to  two  specimens  already  described,  and  to 
two  others  in  the  Museum  of  St.  Bartholomew's  Hospital.  One  of 
these  was  removed  twelve  years  ago,  by  Mr.  Stanley,  from  an  elderly 
man :  it  lay  under  the  vastus  internus  muscle,  and  was  easily  dislodged 


FIBRO-CELLULAR    TUMORS.  413 

from  the  cavity  in  which  it  was  imbedded :  it  Was  a  smooth,  spheroidal 
mass,  thinly  incapsuled,  and  the  bright  yellowish  color  of  its  surface 
made  it  to  be  regarded  as  a  firm-textured  fatty  tumor ;  but  the  micro- 
scope found  little  or  no  fat  in  it,  and  its  present  aspect  leaves  no  doubt 
of  its  nature.  The  patient  died  after  the  operation,  and  had  no  similar 
disease  in  other  parts. 

The  second  of  these  specimens  was  removed,  by  Mr.  Savory,  from 
beneath  the  tensor  vaginae  femoris  of  a  man  38  years  old.  It  was  of 
uncertain  date,  but  had  been  observed  about  five  months  :  it  was  firm, 
elastic,  smooth,  movable,  and  painless.  In  the  operation  it  was  easily 
removed  from  its  resting-place  on  the  rectus  muscle  and  the  inferior 
spine  of  the  ilium ;  the  patient  recovered  perfectly,  and  has  remained 
well  for  nearly  two  years. 

This  tumor  was  a  smooth  oval  mass,  measuring  about  5  inches  by  3|^. 
Both  in  general  aspect  and  in  microscopic  characters  it  might  have 
been  taken  for  a  type  of  the  species,  except  for  the  peculiarity  of  its 
being  at  one  end  capped  with  a  layer  of  cartilage  and  cancellous  bone, 
and  having  nodules  of  cartilage  set  along  the  course  of  one  of  the  chief 
partitions  between  its  lobes  (Fig.  53). 

To  these  specimens  I  may  add  another,  in  the  College  Museum,  of 
which  Mr.  Hunter  has  left  the  record  that  it  was  taken  from  the  thigh, 
and  had  been  supposed  to  be  an  aneurism.* 

These  seem  to  be  the  most  common  seats  of  the  fibro-cellular  tumors, 
but  I  have  preserved  specimens  from  other  parts.  One  was  removed 
by  Mr.  Stanley  from  the  sole  of  the  foot,  where,  surely,  we  might  have 
expected  a  fatty  rather  than  any  other  tumor.  The  patient  was  a 
healthy  man,  41  years  old,  and  the  deeply  bilobed  and  very  prominent 
tumor  lay  in  the  subcutaneous  tissue  over  the  metatarsal  bones,  with 
small  lobular  prolongations  extending  among  the  deeper-seated  tissues. 
It  was  of  eight  years'  growth,  and  nodules  of  cartilage  were  imbedded  in 
the  pliant  and  oedematous  fibro-cellular  tissue  of  many  of  its  lobules. 

Another  of  these  specimens  was  removed  by  Mr.  John  Lawrence, 
with  the  testicle,  within  the  tunica  albuginea  of  which  it  appears  to  be 
entirely  inclosed.  The  patient  was  a  healthy-looking  man,  37  years 
old,  and  the  tumor  had,  in  seven  years,  grown  to  a  measurement  of 
nearly  six  inches  by  four.'  When  first  removed,  it  was  to  the  eye 
exactly  like  a  fatty  tumor,  but  it  contained  no  fat,  and  was  a  typical 
specimen  of  fibro-cellular  tumor  in  a  very  oedematous  or  anasarcous 
state. 

A  third  was  removed  from  over  the  upper  part  of  a  girl's  saphena 
vein,  by  Mr.  Skey.  It  was  completely  incased  in  bone ;  but  its  mass 
was  perfect  soft  and  elastic  fibro-cellular  tissue. 

*  Two  remarkably  good  cases  have  been  recorded  by  Sautesson  in  Hygeia  (translated  in 
Dublin  Journal,  vol.  xx).  They  lay  just  external  to  the  peritoneum,  between  it  and  the 
rectus  and  transversaiis  muscles,  and  both  were  examples  of  very  rapid  growths. 


414  FIBRO-CELLULAR    TUMORS. 

A  fourth  specimen  is  a  tumor  which  I  removed  from  the  orbit  of  a 
man  40  years  old,  in  whom  it  had  been  growing  for  about  eighteen 
months.  It  has  the  general  and  microscopic  characters  of  the  species, 
but  is  very  soft,  and  is  composed  of  a  cluster  of  small  masses,  looking 
almost  like  a  bunch  of  small  gelatinous  polypi  of  the  nose.* 

A  fifth  is  an  oval  bilobed  tumor,  about  half  an  inch  in  diameter, 
which  I  removed  from  a  young  man's  tongue,  in  the  very  substance  of 
which,  near  its  apex,  it  had  been  growing  for  three  years.  It  was 
firmer  than  most  of  the  others,  yet  succulent,  and  formed  of  an  ob- 
scurely filamentous  tissue,  abundantly  nucleated. 

The  specimens  to  which  I  have  now  referred  will  be  sufficient,  I 
think,  to  justify  the  giving  a  distinct  name  to  the  kind  of  tumor  of 
which  they  are  examples.  There  may  be  found,  indeed,  many  speci- 
mens that  will  connect  these  with  fibrous  tumors;  but,  as  I  have  already 
said,  if  we  may,  among  the  natural  tissues,  distinguish  the  fibro-cellular, 
areolar,  or  looser,  from  the  fibrous,  tendinous,  or  denser  form  of  con- 
nective tissue,  so  should  we  make  a  corresponding  distinction  of  the 
tumors  that  are  respectively  like  them. 

1  need  only  add  a  few  words  respecting  the  general  history  of  these 
tumors.  They  have  been  found,  I  believe,  only  in  or  after  the  adult 
period  of  life,  and  in  persons  with  apparently  good  general  health. 
Their  causes  are  wholly  unknown.  Their  development  appears  to  be 
like  that  of  the  natural  fibro-cellular  tissue,  and  I  have  often  found  in 
them  abundant  cells  lengthening  and  attenuating  themselves  as  in  the 
organizing  of  lymph  or  granulations.  These  I  am  disposed  to  regard 
as  proper  rudimental  parts  of  the  growth ;  for  they  are  often  peculiarly 
well  marked,  and  have  no  appearance  of  being  produced  in  disease. 

The  growth  of  these  tumors  is  quick,  in  comparison  with  the  average 
rate  (so  far  as  we  can  roughly  estimate  it)  of  innocent  tumors.  They 
often  enlarge  very  quickly ;  but  this  enlargement  is  probably  not  growth, 
but  swelling,  through  increase  of  the  oedematous  efi'usion  (and  this  dif- 
ference between  growth  and  swelling  may  be  usefully  remembered  in 
the  diagnosis  of  many  tumors).  The  growth  is  usually  painless,  but 
about  the  vagina  is  apt  to  be  too  rapid  for  the  superjacent  tissues.  Its 
possible  extent  is  very  great.  1  have  mentioned  one  tumor  of  44  pounds 
weight,  and  another  of  24  pounds,  which  was  still  growing. 

Of  the  diseases  of  these  tumors  nothing  has  been  yet  observed,  except 
the  sloughing  and  suppuration  that  occurred  in  one  of  the  cases  I  have 
mentioned.     As  to  their  nature,  all  that   has  been  said  implies  that 

*  Three  oases  of  tumor  in  the  orbit,  which,  I  think,  must  have  been  lilce  this,  are  de- 
scribed by  Schuh  (p.  63)  under  the  names  "  Zellgewebsschwamm,"  "  Fungus  cellulosus." 
Besides  the  specimens  above  described,  which  are  all  in  the  Museum  of  St.  Bartholomew's, 
I  have  seen  two  removed  from  the  scalp,  both  of  which,  before  removal,  were  supposed  to 
be  cutaneous  cysts.  A  tumor  removed  by  Dr.  Humphry  (Lectures  on  Surgery,  p.  187)  from 
a  finger,  and  one  described  by  Lebert  (Phys.  Pathol.,  t.  ii,  p.  173)  as  a  fibrous  tumor  of  the 
neck,  were  probably  of  this  kind. 


FIBRO-CELLULAR    TUMORS.  415 

they  are  completely  innocent ;  and  I  have  seen  no  sufficient  reason  to 
doubt  that  they  generally,  or  always,  are  so.  Once,  indeed,  I  think 
such  a  tumor  recurred  after  removal ;  and  once,  in  the  testicle,  a  small 
growth  of  medullary  cancer  existed  near,  but  separate  from  a  large 
fibro-cellular  tumor :  but  these  are  the  only  suspicious  cases  I  have 
known.* 

*  Of  late  years  some  attention  has  been  directed  in  Germany  to  a  form  of  tumor  charac- 
terized by  possessing  as  its  peculiar  elements  perfectly  hyaline,  structureless,  bladder-like 
and  cylindrical  bodies,  from  many  of  which  cactus-lilic  sprouts  or  vegetations  arise.  The 
priority  of  discovery  would  appear  to  rest  with  H.  V.  Meckel,  though  the  first  published 
cases  in  which  the  peculiarities  of  the  tumor  were  indicated  are  by  W.  Busch  (Chir.  Beo- 
bacht.  Berlin,  1854),  and  by  V.  Graefe  (Archiv,  B.  i.  p.  416).  Billroth  was,  however,  the 
first  to  give  any  detailed  account  (Untersuch.  iiber  die  Entw.  der  Blutgefasse,  Berlin,  1856) 
of  the  structures  contained  in  this  form  of  tumor,  and  owing  to  the  numerous  cylindrical 
hyaline  structures  in  it,  he  proposed  the  name  of  Cylindroma,  cylinder-tumor.  The  case 
which  he  examined  was  that  which  had  previously  been  described  by  Busch.  H.  V.  Meckel, 
from  a  supposed  affinity  between  the  cylindrical  bodies  and  cartilage,  gave  the  tumor  the 
name  of  Schlauch-Knorpel-Gesohwulst — cylindrical  cartilaginous  tumor  (Charite  Annalen, 
vii,  Jahrgang,  S.  96).  Another  case  has  since  been  described  by  Volkmann  (Virchow's 
Archiv,  B.  xii,  p.  293,  1S57),  and  Forster  has  described  and  illustrated  a  fifth  and  a  sixth  case 
in  his  Atlas  of  pathological  microscopic  anatomy.      1859.   Taf.  xxx,  p.  47. 

The  tumor  in  the  case  described  by  Busch  and  Billroth,  occurred  in  a  man,  set.  twenty- 
two,  strong  and  healthy,  and  of  a  healthy  family.  It  appeared  in  the  fossa  lachrymalis  of 
the  right  orbit,  and  about  three  years  afterwards  was  removed  by  an  operation.  In  about 
five  months  it  reappeared  and  was  again  removed.  Both  these  tumors  were  examined  by 
Busch  ;  the  first  was  looked  upon  simply  as  a  hypertrophy  of  the  lachrymal  gland,  but  in  the 
second  the  peculiar  cylindrical  structvires  were  observed.  The  tumor  recurred  and  was  re- 
moved five  times  after  the  second  operation,  and  at  length  the  patient  died  about  six  years 
after  its  first  appearance.  No  post-mortem  examination  was  made.  The  five  last  tumors 
were  examined  by  Billroth,  and  it  is  from  them  that  he  draws  up  his  account  of  the  structure. 
They  were  composed  of  larger  and  smaller  lobules,  tolerably  elastic  in  consistence,  each  lobule 
being  invested  by  a  capsule  of  connective  tissue.  The  tumors  on  section  had  a  distinctly 
meshlike  structure,  some  of  the  meshes  being  as  large  as  a  pea,  others  very  much  smaller. 
This  arrangement  was  produced  by  a  network  of  connective  tissue  in  which  bloodvessels 
were  imbedded.  The  contents  of  the  meshes  were  of  a  clear  yellowish-red  color,  readily 
breaking  down,  and  sometimes  even  of  a  pap-like  consistence. 

When  examined  microscopically  a  branched  and  ramifying  system  of  glassy-clear,  ex- 
tremely transparent,  pale  cylinders,  was  seen,  which  frequently  anastomosed,  presented  many 
varicosities,  and  often  swelled  out  into  rounded  knob-like  masses  at  their  extremities.  These 
Billroth  called  the  hyaline  cylinders.  At  other  times  clear,  glassy,  isolated  globular  or  blad-  , 
der-like  structures  were  visible.  Volkmann  described  in  his  case  the  hyaline  cylinders  as 
not  unfrequently  radiating  from  a  common  globular  centre,  and  giving  off  branches  in  a 
cactus-like  manner.  He  and  Forster  consider  that  the  cylinder  and  globules  have  a  definite 
membrane  around  them,  but  Billroth  doubts  if  any  such  membranous  investment  exists. 
Whilst  numbers  of  these  bodies  possessed  no  differentiation  of  structure  in  their  interior,  and 
according  to  Volkmann  were  often  hollow  and  with  fluid  contents,  some  had  extending 
along  their  axes  branched,  star-like  or  spindle-shaped  cells,  with  pale  but  distinct  nuclei, 
others  had  a  fine  string  of  delicate  connective  tissue  running  down  the  interior,  whilst  others 
again  were  packed  full  of  roundish  granular  cells,  and  these  last  Billroth  termed  cell-cylin- 
ders. These  cell-cylinders  had  very  much  the  appearance  of  the  follicles  and  tubes  of 
glands,  and  were  at  first  mistaken  for  them.  The  hyaline  cylinders  and  cell-cylinders  in- 
terlaced with  each  other,  and  formed  together  a  trabecular  arrangement,  in  the  meshes  be- 
tween which  trabeculse  crowds  of  small,  round,  oval,  or  polygonal  cells  were  imbedded. 
Billroth  described  in  some  of  the  hyaline  cylinders  the  developinent  of  bloodvessels  by  the 
coalescence  of  spindle-like  cells,  an  observation  which  has  been  confirmed  by  Forster. 


416  painful   subcutaneous  tumors. 

Painful  Subcutaneous  Tumors. 

A  group  of  tumors,  peculiar  for  the  pain  with  which  they  are  con- 
nected, is  thus  named,  and  is  so  remarkable  as  to  justify  giving  a  de- 
scription of  them  separate  from  that  of  the  fibro-cellular  and  fibrous 
tumors,  with  which,  considering  their  other  characters,  the  chief  exam- 
ples of  them  might  be  placed. 

The  painful  subcutaneous  tumor,  or  tubercle,  has  been  often  well 
described  in  relation  to  its  general  characters.  Its  intense  painfulness 
was  too  striking  to  escape  observation.  It  was  described  by  A.  Petit, 
Cheselden,  Camper,  and  others ;  but  the  first,  and  to  this  time  the  best, 
general  account  of  the  disease,  drawn  from  many  instances,  was  given 
by  Mr.  William  Wood,  in  1812.*  Dupuytren  added  many  instances 
to  those  which  he  copied  from  Mr.  Wood's  paper,  and  made  the  disease 
much  more  widely  known. f 

The  especial  seat  of  growth  of  these  little  tumors  is,  as  their  name 
implies,  in  the  subcutaneous  areolar  and  adipose  tissue.  They  are  most 
frequent  in  the  extremities,  especially  the  lower :  very  rarely  they  occur 
on  the  trunk,  or  the  face.|  They  are  about  four  times  more  frequent 
in  women  than  in  men ;  they  rarely,  if  ever,  begin  to  form  before  adult 
life,  or  after  the  commencement  of  old  age.     It  is  seldom  that  local 

The  oliaracteristic  cylindrical  and  globular  structures  are  now  mostly  regarded  as  belong- 
ing to  that  softer,  modified,  and  more  rudimental  form  of  connective  tissue  which  has  been 
recently  named  mucous  tissue.  Volkmann  considers  that  the  globules  are  formed  by  the  en- 
largement of  pre-existing  tissue-cells  into  transparent  ball-like  masses,  and  that  from  these, 
as  from  a  mother-cell,  the  hyaline  cylinders  branch  out  by  a  system  of  lateral  sprouting.  In 
these  cylinders  and  globules  a  process  of  cell-formation  may  go  on  from  the  old  cell-nucleus, 
by  endogenous  cell-multiplication,  until  they  become  packed  with  small  cells. 

Although  the  structures  now  described  were  at  first  thought  to  be  characteristic  of  a  dis- 
tinct form  of  tumor,  yet  the  later  observations  hardly  appear  to  bear  out  the  original  supposi- 
tion. The  cases  on  which  Volkmann  and  Forster  founded  their  descriptions  were  rapidly 
spreading  cancroid  ulcers  with  which  the  characteristic  hyaline  cylinders  and  globules  were 
incorporated,  from  which  circumstance  the  latter  describes  the  tumors  by  the  name  of  mucous 
cancroids  (Schleim-Cancroids).  Bilhoth  himself,  in  a  later  communication  "  On  Tumors  of 
the  Salivary  Glands"'  (Virchow's  Archiv,  1859),  states  that  he  has  not  unfrequently  found, 
in  tumors  of  the  parotid,  structures  corresponding  to  those  described  by  him  in  Cylindroma. 
He  is  now,  therefore,  with  Forster,  disposed  to  regard  the  cylinders  and  globules  as  growths 
of  mucous  tissue,  which  may  combine  with  the  textures  of  other  forms  of  tumors. 

It  is  in  accordance  with  the  view  that  these  structures  are  closely  allied  to  the  more  rudi- 
mental forms  of  connective  tissue,  that  this  account  of  them  has  been  inserted  as  an  appendix 
to  the  description  of  the  fibro-cellular  tumors.  Any  classification,  however,  at  present 
adopted,  must  be  regarded  as  merely  provisional,  the  number  of  cases  up  to  this  time  re- 
corded, in  which  these  structures  have  been  met  with,  being  too  few,  and  the  conditions 
which  determine  their  formation  being  too  little  understood,  to  permit  one  to  come  to  a  final 
conclusion.  It  may  have  happened  that,  in  some  of  the  examples  of  the  fibro-cellular 
tumors  described  in  the  text,  the  peculiar  cylindrical  structures  may  have  existed,  though, 
through  imperfect  examination,  they  were  not  recognized. 

*  Edinburgh  Med.  and  Surg.  Journal,  viii,  1812.  Mr.  Wood  first  gave  these  tumors  the 
appropriate  name  which  they  have  since  borne. 

f  Legons  Orales,  i,  5/iO.     He  named  them  fibro-cellular  encysted  tumors. 

J  One  is  mentioned  by  Mr.  Csesar  Hawkins,  as  removed  from  the  cheek  by  Sir  B.  C. 
Brodie  (Medical  Gazette,  vol.  xxi,  p.  926) ;  and  one  by  Dupuytren. 


PAINFUL    SUBCUTANEOUS    TUMORS.  417 

injury,  or  any  other  cause,  can  be  assigned  for  their  occurrence.  The 
tumor  usually  lies  just  beneath  the  skin,  scarcely  prominent ;  it  has  a 
capsule  loosely  connected  with  all  the  surrounding  parts,  unless  it  be 
to  the  cutis,  to  which  it  may  be  tightly  fixed,  and  which,  in  such  cases, 
is  generally  thin,  tense,  polished,  and  like  a  superficial  scar.  Some- 
times the  small  bloodvessels  of  the  skin  over  and  around  the  tumor  are 
enlarged  and  tortuous,  like  those  near  a  cutaneous  ngevus  ;  but,  else,  all 
the  adjacent  parts  appear  healthy. 

Tumors  of  this  kind  rarely  exceed  half  an  incb  in  diameter  ;  they  are 
usually  spheroidal,  oval,  or  cylindriform ;  they  are  firm,  nearly  hard, 
tense,  and  very  elastic.  Their  outer  surface  is  usually  smooth,  bright, 
yellowish,  or  grayish,  or  pure  white  ;  and  their  sections  have  the  same 
aspect  and  consistence,  or  are  varied  by  an  obscure  appearance  of  pure 
white  fibres  traversing  a  grayish  basis.* 

Among  the  painful  subcutaneous  tumors  that  I  have  been  able  to  ex- 
amine microscopically,  one  was  composed  of  dense  fibrous  tissue,  with 
filaments  laid  inseparably  close  in  their  fasciculi,  and  compactly  inter- 
woven. These  appeared  to  have  been  formed  in  or  from  a  nucleated 
blastema  ;  for  thickset,  oval,  and  elongated  nuclei  were  displayed  when 
acetic  acid  was  added.  Another  was  composed  of  well-formed  fibro- 
cellular  tissue,  with  bundles  of  parallel  undulating  filaments,  matted  or 
closely  interwoven.  With  these  were  elongated  fibro-cells,  the  pro- 
ducts, perhaps,  of  inflammation,  to  which  the  tumor  appeared  to  have 
been  subject.  The  substance  between  the  filaments,  and  that  from 
which  they  were  probably  developed,  was  here,  also,  a  nucleated  blas- 
tema. A  third  specimen  presented  obscure  appearances  of  a  filamen- 
tous structure,  but  no  separable  filaments :  it  seemed  composed  wholly 
of  such  nucleated  blastema  as  was  exposed  by  the  action  of  acetic  acid 
on  the  former  specimens.  In  some  parts,  also,  this  presented  appear- 
ances of  filaments  and  nuclei  arranged  in  concentric  circles  around 
small  cavities. f  A  fourth,  which  had  existed  for  many  years  at  the 
end  of  a  woman's  thumb,  consisted  of  large  clear  nuclei  in  a  dimly- 
shaded  homogeneous  substance.  One,  from  the  front  of  the  abdomen, 
was  like  a  common  fatty  tumor. 

From  these  examples,  or,  at  least,  from  the  first  three,  we  may  be- 
lieve that  the  painful  subcutaneous  tumors  may  be  formed  of  either  the 
looser  fibro-cellular  or  more  dense  fibrous  form  of  connective  tissue,  in 
either  a  rudimental  or  a  perfect  state.  They  may  also,  I  believe,  be 
fibro-cartilaginous,  as  described  by   Professor   Miller,|  and  by  many 

*  Sometimes  the  tumor  has  a  central  cavity  filled  with  fluid,  as  in  two  cases  by  Mr.  Car- 
ruthers,  in  Edin.  Med.  and  Surg.  Jour.,  vol.  xxxiii;  but  it  is  observable  that  in  one  of  these, 
occurring  in  a  man,  a  visible  nerve  was  connected  with  the  tumor.  Perhaps  this  was  a 
neuroma  ;  for  in  these  the  cystic  character  is  not  unfrequent. 

f  Like  those  drawn  from  a  fibrous  tumor  of  the  uterus  by  Prof.  Bennett  (On  Cancerous 
and  Cancroid  Growths,  p.  189). 

X  Principles  of  Surgery,  p.  602,  3d  Ed.  An  engraving,  from  the  sketch  by  Prof.  Ben- 
nett, makes  this  the  only  sure  instance  of  fibro-cartilaginous  structure.     In  the  other  recorded 


418  PAINFUL    SUBCUTANEOUS    TUMORS. 

Other  writers.  But  whatever  such  slight  diversity  of  tissue  they  may 
present,  the  characteristic  of  all  these  tumors  is  their  pain;  pain  which 
may  precede  all  notice  of  the  tumor,  or  may  not  commence  till  much 
later,  or  may  be  contemporary  with  it,  but  which,  when  once  it  has  set 
in,  may  rise  to  very  agony,  such  as  I  suppose  is  not  equalled  by  any 
other  morbid  growth.  It  is  not  often  constant ;  but,  generally,  without 
evident  cause,  or  with  only  a  slight  touch  of  the  tumor,  a  paroxysm  of 
pain  begins,  and,  gradually  increasing,  soon  reaches  a  terrible  severity. 
Beginning  at  or  near  the  tumor,  it  gradually  extends  into  all  the  adja- 
cent parts,  often  flashing,  like  electric  shocks,  from  one  part  of  the  limb 
to  another,  or  to  the  whole  trunk.  Such  a  paroxysm  may  continue  for 
a  few  minutes,  or  for  several  hours ;  then  it  gradually  subsides,  leaving 
the  parts  sore  and  tender.  While  it  lasts,  the  tumor,  whatever  may  be 
its  condition  at  other  times,  is  always  exquisitely  sensitive :  the  mus- 
cles of  the  limb  may  act  with  irregular  spasms  ;  or  general  convulsions, 
like  those  of  an  epileptic  seizure,  may  ensue ;  or,  the  patient  falls  as  if 
sunk  by  the  intolerable  pain,  and  faints.  Sometimes  too,  the  tumor 
itself  swells,  the  bloodvessels  around  it  become  larger  and  more  tor- 
tuous, and  the  skin  becomes  oedematous  or  congested,  imitating  the 
change  which  sometimes  ensues  in  a  neuralgic  part.  There  are  many 
diversities  in  the  characters  and  modes  of  the  pain  ;  but  this  belongs  to 
all  the  instances  of  it, — that  its  intensity  is  altogether  disproportionate 
to  its  apparent  cause,  and  that  it  cannot  be  explained  by  anything  that 
can  be  seen  in  the  structure  or  relations  of  the  tumor. 

This  pain  suggests  interesting  questions  in  relation  to  the  pathology 
of  tumors  ;  but,  before  considering  it,  let  me  add  some  facts  to  complete 
the  history  of  these.  They  appear  usually  to  be  of  very  slow  growth. 
One,  which  I  removed  from  the  end  of  a  thumb,  had  existed  fourteen 
years,  and  was  less  than  a  quarter  of  an  inch  in  diameter.  Another, 
which  I  removed  from  the  leg  of  an  elderly  woman,  had  gradually  in- 
creased for  ten  years  ;  yet,  at  last,  it  was  less  than  half  an  inch  in 
diameter.  In  other  cases  they  may  more  quickly  attain  the  same  size ; 
but  this  seems  their  limit ;  and,  for  any  number  of  years,  they  may  re- 
main sources  of  intense  pain,  and  yet  undergo  no  apparent  change  of 
size  or  structure.  They  are  usually  single.  I  have  found  only  one 
case  in  which  more  than  one  existed  :  in  this  case  three  lay  close  to- 
gether over  the  great  gluteal  muscle.*  When  excised,  they  are  not  apt 
to  recur.  I  removed  one  from  the  back  of  the  leg  of  a  lady  28  years 
old,  from  Avhom,  two  years  previously,  a  similar  growth  was  excised 
from  the  same  part.  After  the  first  operation  the  pain  was  scarcely 
changed ;  after  the  second  it  ceased,  and  never  returned.  Sir  Astley 
Cooperf  removed  two  painful  tumors,  at  an  interval  of  a  year,  from  a 
young  lady's  leg ;  but  these  are  the  only  instances  of  apparent  recur- 

cases  the  microscope  was  not  used  ;  and  the  naked  eye  cannot  discern  between  fibrous  car- 
tilage and  dense  fibrous  tissue. 

-;<•  -w    Wood,  1.  c.  t  Illustr.  of  Diseases  of  the  Breast,  p.  S4. 


PAINFUL    SUBCUTANEOUS    TUMORS.  419 

rence  that  I  have  found.  I  believe  that  they  have  no  tendency  to 
ulcerate,  or  to  assume  any  of  the  peculiar  characters  of  malignant  dis- 
ease.* 

In  considering,  now,  the  painfulness  of  these  tumors,  the  first  ques- 
tion is  their  relation  to  nerves :  are  nerves  involved  in  them  ?  and  do 
they,  as  Velpeauf  seems  to  hold,  differ  from  neuromata,  i.  e.  from  the 
fibrous  or  fibro-cellular  tumors  within  the  sheaths  of  the  nerves,  only  in 
their  position  ?  are  they  only  tumors  within  the  superficial  or  subcuta- 
neous nerves  ? 

The  general  opinion  is  against  this  supposition.  Dupuytren  says 
that  he  dissected  several  of  these  tumors  with  minute  care,  and  never 
saw  even  the  smallest  nervous  filaments  adhering  to  their  surface.  I 
have  sought  them  with  as  little  success  with  the  microscope.  Of  course, 
I  may  have  overlooked  nerve-fibres  that  really  existed.  It  is  very  hard 
to  prove  a  negative  in  such  cases  ;  and  cases  of  genuine  neuroma,  i.  e. 
of  a  fibrous  tumor  within  the  sheath  of  a  nerve,  do  sometimes  occur 
which  exactly  imitate  the  cases  of  painful  subcutaneous  tumor.  Such 
a  case  was  under  Mr.  Stanley's  care  some  years  ago.  An  elderly  gen- 
tleman had  for  two  years  observed  a  small  subcutaneous  tumor  over  the 
lower  part  of  the  semi-membranosus  muscle.  It  was  easily  movable, 
and,  till  within  the  last  three  months,  had  not  been  inconvenient ;  but 
at  this  time  it  became  the  seat  and  source  of  pain  exactly  like  that  of  a 
painful  subcutaneous  tumor.  It  was  removed;  and  I  was  able  to  trace, 
with  the  microscope,  an  exceedingly  slender  nerve,  the  filaments  of 
which  were  spread  out  over  one  part  of  the  tumor.  The  tumor  was 
within  the  neurilemma,  and  was  uniformly  firm,  elastic,  yellowish,  and 
composed  of  well-formed  fibrous  tissue. 

Many  that  have  been  called  painful  subcutaneous  tumors  may  have 
been  such  neuromata  as  this  was.  Still,  I  am  disposed  to  think  that  most 
of  them  are  only  so  connected  with  nerves  as  ordinary  innocent  tumors 
are,  that  receive  a  few  nerve-fibres  in  their  substance.  For  (1)  the  con- 
nection of  the  nerves  with  even  very  small  neuromata  is  not  so  difficult 
to  demonstrate,  but  that  it  should  have  been  found,  if  it  had  existed,  in 
some  of  the  many  painful  tumors  that  have  been  examined.  (2)  The 
neuromata  often  occur  in  large  numbers  in  the  same  patient ;  the  pain- 
ful subcutaneous  tumor  is  nearly  always  single.  (3)  The  neuromata 
usually  grow  constantly,  and  seem  to  have  no  limit  of  size ;  even  when 
subcutaneous,  they  commonly  exceed  the  size  of  the  painful  tumors, 
which  generally  grow  to  a  certain  small  size,  and  in  it  remain  station- 
ary.    (4)  Neuromata  are  most  frequent  in  the  male,  the  painful  subcu- 

*  Dr.  Warren  (On  Tumors,  p.  60)  speaks  of  a  malignant  form  of  the  disease  in  which 
the  lymphatics  are  aflected,but  relates  no  case  of  it.  The  case  requiring  amputation  which 
lie  relates  appears  to  have  owed  its  severity  to  the  treatment.  Dupuytren  (Le9ons  Orales, 
i,  542)  says  they  have  or  may  acquire  a  scirrhous  nature,  and  then  end  with  cancerous  soft- 
ening ;  but  he  refers  to  only  one  case  justifying  such  expressions,  and  this  case  is  imperfectly 
described. 

■j-  Medecine  Operatoire,  torn,  iii,  p.  101. 


420  PAINFUL    SUBCUTANEOUS    TUMORS. 

taneous  tumors  in  the  female  sex.  An  analysis  of  26  cases  of  neuroma 
taken  promiscuously  showed  that  19  had  occurred  in  men,  and  7  in 
women ;  while  in  28  cases  of  painful  subcutaneous  tumors  23  were  in 
women,  and  5  in  men  ;  evidence  which  is  almost  conclusive  for  the  differ- 
ent natures  of  the  two  diseases. 

However,  even  if  it  could  be  proved  that  these  painful  tumors  are 
within  nerves,  the  question  respecting  the  source  of  pain  would  not  be 
fully  answered.  We  cannot  ascribe  the  pain  to  merely  the  altered  me- 
chanical condition  of  the  nerve-fibres ;  for  tumors  that  are  evidently 
within  nerves  are  not  always,  nor  even  usually,  painful.  It  is  remark- 
able that,  in  nearly  all  the  cases  in  which  large  tumors  have  existed  in  the 
trunks  of  nerves,  there  has  been  little  or  no  pain.  The  facts  collected 
by  Dr.  Smith*  are  clear  on  this  point.  Moreover,  the  subcutaneous 
tumors  themselves  often  remain  long  painless,  and  then  become,  without 
any  other  apparent  change,  extremely  painful ;  and  there  are  instances 
of  tumors  exactly  resembling  them,  except  in  that  pain  has  never  been 
felt  in  them.  I  removed  such  a  one  from  a  lady's  forehead.  It  was 
about  as  large  as  a  pea,  had  been  two  years  growing  in  the  subcuta- 
neous tissue,  and  had  never  given  pain  except  once,  when  it  was  severely 
struck.  It  had  all  the  apparent  characters  of  structure  of  the  painful 
subcutaneous  tumor.  I  repeat,  therefore,  that  we  cannot  assign  the 
pain  in  these  cases  entirely  to  an  altered  mechanical  condition  of  the 
nerve-fibres  in  or  near  the  tumor.  We  must  admit,  though  it  be  a  vague 
expression,  that  the  pain  is  of  the  nature  of  that  morbid  state  of  nerve- 
force  which  we  call  neuralgic. 

Of  the  exact  nature  of  this  neuralgic  state,  indeed,  we  know  nothing  ; 
but  of  its  existence  as  a  morbid  state  of  nerve-force,  or  nervous  action, 
we  are  aware  in  many  cases,  in  which  we  can  as  yet  trace  no  organic 
change,  and  in  many  more,  in  which  the  sensible  organic  change  of  the 
nerves  is  inadequate  to  the  explanation  of  the  pain  felt  through  them. 
In  both  these  sets  of  cases  we  assign  the  pain  (speaking  vaguely)  to  a 
functional,  rather  than  to  an  organic,  disorder  of  the  nerves ;  to  a  dis- 
order commencing  in  the  nerves  of  the  part  which  is  the  focus  of  the 
pain,  but  transmitted  from  them  to  others  which,  in  the  nervous  centres, 
are  connected  with  them. 

With  this  view  of  the  neuralgic  nature  of  the  pain  in  the  subcutaneous 
tumors  many  of  their  characters  and  circumstances  agree.  The  pain 
is  commonly  paroxysmal,  and  sometimes  regularly  periodical ;  it  is 
difiuse,  or  flashing,  electric,  and  most  intense ;  it  often  excites  reflex 
spasmodic  movements,  or  more  severe  and  general  convulsions ;  though 
not  peculiarly  frequent  in  persons  of  extreme  sensibility,  yet  it  is  often 
aggravated  by  mental  emotions,  and  the  other  excitants  of  neuralgic 
pains ;  it  is  sometimes  increased,  or  first  felt,  about  the  time  of  the 
cessation  of  the  menstrual  discharge  ;  it  sometimes  remains  at  or  about 
the  seat  of  the  disease  for  a  long  time  after  the  removal  of  the  tumor  ;  it 

*  Treatise  on  Neuroma. 


PAINFUL     SUBCUTANEOUS    TUMORS.  421 

is  sometimes  attended  with  what  is  regarded  as  reflex  vascular  fulness, 
but  it  precedes  no  organic  change. 

The  consideration  of  the  probably  neuralgic  nature  of  the  pain  in 
and  about  these  tumors  is  of  interest  in  relation  to  the  pathology  of 
many  others.  The  pains  of  many  other  tumors  are  probably,  in  greater 
or  less  measure,  of  the  same  nature. 

The  irritable  tumor  of  the  breast  may  be  called  a  neuralgic  tumor. 
Sir  Astley  Cooper's  plates  show,  indeed,  that  some  which  he  thus  called 
were  like  the  painful  subcutaneous  tumors  ;  but  the  more  frequent  are, 
I  believe,  mammary  glandular  tumors,  imitating  in  their  structure  the 
mammary  gland  itself,  or  small  portions  of  indurated  gland.  I  derive 
this  belief  from  the  general  appearance  and  description  of  several  spe- 
cimens, and  from  what  I  found  in  two  cases  with  the  microscope.  A 
woman,  45  years  old,  was  under  my  care  with  a  small  tumor  lying  deep 
in  her  breast,  which  felt  hard  and  not  movable,  except  with  the  tissue 
around  it.  She  had  been  aware  of  this  tumor  for  a  month,  and  during 
all  the  time  it  had  been  the  source  of  intense  "  darting  and  dragging" 
pain,  which  often  extended  from  it  through  the  chest  to  the  shoulders, 
and  along  the  neck  and  arms.  The  pain  was  described  as  so  like  that 
commonly  assigned  to  cancer  of  the  breast,  that,  judging  from  it,  and 
from  the  age  and  other  circumstances  of  the  patient,  one  could  not  but 
fear  she  had  cancer.  The  doubt  rendered  it  proper  to  make  an  explo- 
ratory incision  at  the  commencement  of  the  operation.  This  was  done, 
and  the  tumor  having  no  cancerous  aspect,  was  alone  removed.  It 
proved  to  be  a  perfect  example  of  mammary  glandular  tumor,  such  as  I 
shall  more  fully  describe  in  a  future  lecture.  Thus  the  case  seemed  to 
be  one  of  mere  neuralgia  in  a  glandular  tumor  of  the  breast :  and  it 
may  be  added,  that  it  was  only  a  striking  instance  of  an  ordinary  fact ; 
for  such  tumors  are  often  at  times  extremely  painful. 

Similar  instances  might  be  found,  I  believe,  in  tumors  of  other  struc- 
tures ;  but,  without  entering  further  on  their  history,  I  would  suggest 
that  the  account  of  all  these  painful  tumors  makes  it  probable  that  the 
pain  the  patients  feel  is,  in  great  measure,  neuralgic  or  subjective  ;  that 
it  has  the  tumor  indeed,  for  an  exciting  cause  ;  but  that  it  owns,  besides, 
some  morbid  condition  inherent  or  cumulative  in  the  nerves  themselves, 
so  that  at  times  they  respond,  with  a  morbid  exaggeration,  to  an  habi- 
tual or  slightly  increased  stimulus.  And  if  this  be  true  of  the  most 
painful  tumors,  it  is  probably  true,  in  various  measures,  of  many  others. 


422  FIBROUS    TUMORS. 


LECTURE    XXV. 

FIBROUS    TUMORS. 

The  name  of  "  fibrous  tumor"  appears  the  best,  among  the  sixteen  or 
more,  by  which  different  writers  have  described  the  tumors  whose  chief 
characteristic  is  their  likeness  to  the  natural  fibrous,  tendinous,  or 
denser  form  of  connective  tissue  of  the  body.  This,  at  least,  seems  the 
best  for  a  general  designation  ;  and  to  those  among  them  which  are  con- 
structed of  more  than  one  elementary  tissue  we  may  give  such  names 
as  "fibro-muscular,"  "  fibro-elastic,"  "  fibro-cartilaginous,"  &c. 

The  most '  frequent  and  notorious  examples  of  the  species  are  the 
fibrous  tumors,  or  fibrous  bodies,  of  the  uterus ;  the  "  hard,  fleshy  tu- 
bercle of  the  uterus,"  as  it  was  described  by  Dr.  Baillie.  From  these, 
chiefly,  the  general,  though  not  all  the  microscopic,  characters  of  the 
species  may  be  described. 

First,  however,  the  usual  distinction  must  be  drawn  between  the  tu- 
mors and  the  outgrowths  of  the  same  structure.  The  uterus  presents 
examples  of  both. 

The  Fibrous  Polypi  of  the  uterus,  more  properly  so  called,  are 
continuous  outgrowths  of  and  from  the  substance  of  the  uterus ;  the 
mucous  membrane  and  the  muscular  and  fibrous  tissues  of  the  uterus, 
growing,  in  variety  of  proportions,  into  its  cavity  and  that  of  the  vagina. 
The  fibrous  tumors  are  discontinuous  growths  of  similar  tissue  in  or  near, 
not  of,  the  substance  of  the  uterus.* 

The  distinction  is  often  difiicult  to  make  during  life ;  for  the  pendu- 
lous, polypoid,  and  narrow-stemmed  outgrowth  may  be  imitated,  in  all 
its  external  characters,  by  a  tumor  growing  near  the  surface  of  the 
uterus,  and  projecting  into  its  cavity,  with  a  gradual  thinning  invest- 
ment of  its  muscular  and  mucous  tissues.  On  dissection,  however,  or 
in  such  a  section  as  the  adjoining  diagram  (Fig.  54)  may  represent, 
the  continuity  of  the  polypus  or  outgrowth,  A,  and  the  discontinuity  of 
the  more  commonly  occurring  tumor,  b,  may  generally  be  discerned, 
even  in  specimens  which,  like  two  in  the  Museum  of  St.  Bartholomew's 
Hospital,  are,  in  external  appearance,  exactly  alike  (xxxii,  12  and  34). 

Similar  diff'erences  exist  among  what  are  classed  together  as  fibrous 
tumors  of  bone  or  periosteum :  some,  as  we  shall  see,  are  tumors ;  some 
are  outgrowths,  and  the  line  of  distinction  cannot  be  well  drawn. 

Fibrous  outgrowths  are  also,  sometimes,  found  in  the  form  of  polypi 
suspended  in  the  pharynx,  or  in  the  chambers  of  the  nose,  or  in  some 

*  The  distinction  is  expressed  by  M.  Cruveilhier  (Anatomie  Patliologique)  by  the  terms 
"corps  fibreux  implantes,"  and  "corps  fibreux  non  implant^s ;'  but  the  "corps  fibreux"  of 
tlie  breast,  which  were  described  by  him, and  led  to  the  renowned  discussion  at  the  French 
Academy  of  Medicine,  were,  for  the  most  part,  mammary  glandular  tumors,  and  nearly  solidi- 
fied proliferous  cysts. 


FIBROUS    TUMORS. 


423 


54.* 


of  the  cavities  communicating  with  them.  But  I  have  not  been  able  to 
examine  any  of  these  minutely  in  the  recent  state ;  and  I  have  seen 
so  few  in  any  condition,  that  I  cannot  tell 
whether  some,  or  even  many,  of  them  are  not 
separate  fibrous  tumors,  projecting  the  mucous 
membrane,  and  pendulous,  as  fatty  tumors 
often  are,  when  they  grow  just  beneath  the 
cutis.  Neither  the  description  by  Schuh,  ac- 
curate as  it  is  in  other  points,  nor  any  other 
that  I  remember,  decides  this.  The  same  un- 
certainty exists  as  to  the  relations  of  the  ex- 
tremely rare  fibrous  polypi  of  the  oesopha- 
gus and  larynx.  The  fibrous  structure  of  all 
these  growths  is  well  marked,  but  compara- 
tively soft  and  elastic,  and  intermediate  be- 
tween the  structures  proper  to  the  typical 
examples  of  the  fibro-cellular  and  the  fibrous 
tumors. 


The  Fibrous  Tumors,  of  which  alone  I  shall 
now  speak,  appear  to  have  a  natural  tendency 
towards  a  spherical  or  oval  shape,  with  a  smooth 
or  superficially  lobed  surface  ;  but  from  these 
marks  they  often  deviate,  in  adaptation  to 
mutual  pressure  or  the  different  resistances  of 
surrounding  parts.  When,  for  example,  a 
fibrous  tumor  is  pendulous,  its  more  dependent  portion  usually  grows 
most,  or  is  most  swollen;  it  tends  from  the  spheroidal  to  the  pyriform 
shape,  but  retains  a  smooth  surface :  when  one  grows  into  a  cavity,  it 
is  apt  to  assume  the  shape  of  that  cavity,  whatever  it  may  be,  or  else  to 
become  deeply  lobed.  Such  varieties  as  these  are  often  seen  in  the 
fibrous  tumors  of  the  upper  jaAv,  according  as  they  grow  into  the  cavity 
of  the  mouth,  or  in  other  directions ;  and  greater  diversities  occur  among 
many  specimens  of  the  fibrous  tumors  of  the  uterus. 

The  fibrous  tumors  growing  in  solid  organs  have  usually  a  complete 
connective  tissue  capsule ;  and  in  the  uterine  walls  this  is  peculiarly 
dry  and  loose,  so  that,  when  one  cuts  on  the  tumor,  it  almost  of  itself 
escapes  from  its  cavity.  So,  too,  are  covered  the  fibrous  tumors  in  the 
subcutaneous  tissue  and  in  the  nerves,  and  those  parts  of  the  fibrous 
tumors  and  outgrowths  from  bones  which  are  in  contact  with  other 
tissues  than  those  from  which  they  spring. 

To  the  touch  the  fibrous  tumors  are  usually  very  firm,  often  extremely 

*  Fig.  54,  diagram-sections  of  a  uterine  outgrowth  (a)  and  of  a  uterine  tumor  (b).  Both 
are  like  polypi,  but  the  former  is  continuous  with  the  substance  of  the  uterus ;  the  latter  is 
discontinuous.  See  cases  by  Davaine  and  Laboulliene  in  the  C.  R.  de  la  Soc.  de  Biologic 
for  1855,  p.  142. 


424  FIBROUS    TUMORS. 

SO ;  they  may  even  be  as  hard  and  incompressible  as  hard  cancers.  If 
they  are  soft,  or  "fleshy,"  or  succulent,  it  is,  I  think,  always  through 
oedema  or  inflammatory  softness  and  infiltration  of  their  substance ;  for 
such  characters  as  these  are  rare,  except  in  the  case  of  the  pendulous 
or  protruding  tumors,  or  in  those  that  are  manifestly  diseased.  More- 
over, in  all  ordinary  cases,  the  fibrous  tumors  are  heavy,  very  elastic, 
and  very  tense,  so  that  their  cut  surfaces  rise  in  convexities,  like  those 
of  intervertebral  fibrous  cartilages. 

In  the  examination  of  sections,  of  which  Fig.  57  may  represent  an 
ordinary  example,  the  most  usual  characters  that  one  sees  are,  that  the 
tumors  present  a  grayish  basis-substance,  nearly  homogeneous,  and  in- 
tersected with  opaque,  pure  white  bands  and  lines.  They  have  a  general 
resemblance  in  their  aspect  to  a  section  of  fibro-cartilage,  such  as  that 
of  the  semilunar  or  the  intervertebral  cartilages.  Many  varieties,  how- 
ever, appear;  the  basis-substance  tending  towards  yellow,  brown,  or  blue, 
and  the  white  lines  being  variously  arranged. 

It  would  be  tedious  to  describe  minutely  these  various  arrangements : 
let  it  sufiice  that  there  are  three  principal,  but  often  mingled,  plans.* 
In  some  tumors,  the  bundles  of  white  fibres  tend  to  construct  concentric 
circles  round  one  or  many  centres ;  so  that,  in  the  section,  we  have  a 
vague  imitation  of  the  aspect  of  one  or  more  intervertebral  fibro-carti- 
lages,  the  appearance  of  concentric  curved  fibres  representing  an  ar- 
rangement of  layers  successively  inclosed,  in  the  same  involute  manner 
as  I  described  in  one  of  the  varieties  of  fatty  tumors  (p.  897).  These 
are  generally  the  hardest  and  least  vascular  of  the  fibrous  tumors; 
usually,  too,  they  are  spherical. 

In  another  variety  of  the  tumors,  the  white  bands  course  in  variously 
sweeping  curves  and  undulations,  the  components  of  the  large  bundles 
diverging  and  interlacing. 

In  yet  another  variety,  the  fibres  are  less  fasciculate,  and  appear  as 
if  closely  matted  in  a  nearly  uniform  white  substance ;  and,  in  the  ex- 
treme specimens  of  this  form,  which  are  most  commonly  found  on  or  in 
the  jaw-bones,  a  fibrous  structure  is  scarcely  to  be  discerned  with  the 
naked  eye :  they  look  nearly  uniform,  glistening,  pale  or  white,  and 
very  firm ;  but  the  microscope  proves  their  identity  with  the  other 
varieties. 

As  on  the  exterior,  so  in  sections,  these  tumors  present  various  de- 
grees of  lobular  arrangement.  Some  are  uniform  and  scarcely  parti- 
tioned ;  while  others  are  formed  in  distinct  and  easily  separable  pieces ; 
and  between  these  are  numerous  intermediate  forms. 

As  a  general  rule,  the  vascularity  of  a  fibrous  tumor  is  in  an  inverse 
proportion  to  its  singleness  and  toughness  of  construction ;  for  the 
bloodvessels,  as  in  the  natural  fibrous  structures,  are  distributed  chiefly 
or  exclusively  in  the  looser  areolar  tissue  partitioning  and  investing  the 

*  See  Nos.  2666,  2671,  2672,  in  the  Museum  of  the  College  of  Surgeons. 


FIBROUS    TUMORS. 


425 


Fig.  554 


denser  substance.  The  tumors  thus  present  various  degrees  of  vascu- 
larity. Some,  when  the  vessels  of  the  uterus  are  fully  injected,  appear 
still  quite  white ;  but  some  appear  as  highly  colored  with  the  injection 
as  the  uterus  itself.* 

In  microscopic  examination,  one  finds,  among  the  fibrous  tumors, 
certain  varieties  of  composition  which  are  not  always,  if  at  all,  expressed 
in  their  more  manifest  characters.  In  all,  I  believe,  a  large  portion  of 
the  mass  consists  of  tissue  resembling  the  tendinous  or  fibrous ;  being 
composed  of  exceedingly  slender,  uniform,  pellucid  filaments,  undu- 
lating or  crooked,  more  or  less  perfectly  developed,  and  variously  ar- 
ranged, f  This  is  the  case  in  all  parts  of  the  tumor ;  in  the  more 
homogeneous  basis-substance  as  well  as  in  the  intersecting  bands ;  the 
microscopic  diiferences  between  these  parts  consisting,  I  think,  only  in 
the  less  or  more  regular  arrangement  of  the  fibrous  structure  or  fibrous 
appearance  of  the  tissue.  But  in  different  specimens,  or  even  in 
difi"erent  parts  of  the  same,  the  tissue  appears  less  or  more  perfectly 
formed ;  so  that,  while  in  some,  distinct  filaments  or  undulating  fasci- 
culi may  be  dissected  out,  in  others  there  is  rather  a  fibrous  appearance 
than  a  fibrous  structure.  Commonly,  too,  one  finds 
nuclei  or  cytoblasts  strewn  through  the  substance  of 
the  tumor  ;  the  less  abundantly,  I  think,  the  more  per- 
fect is  the  fibrous  character  of  the  tissue.  But  in  all 
these  respects,  there  are  not,  I  think,  more  or  other 
diiferences  among  fibrous  tumors  than  in  a  series  of 
natural  fibrous  tissues. 

With  these  constituents  other  elementary  tissues  are 
mingled  in  certain  fibrous  tumors.  In  those  in  the 
uterus  (just  as  in  the  uterus  itself),  smooth  or  organic 
muscular  fibres  are  more  or  less  abundant. §  I  have 
not,  indeed,  seen  such  a  specimen  as  would  quite  justify 
the  name  of  "muscular"  tumors,  assigned  by  Vogel : 
but  the  mingling  of  the  muscular  fibres,  in  imitation  of 

*  Remarkably  good  specimens  illustrating  this  point  are  in  the  Museum  of  the  Middlesex 
Hospital.  In  the  Anatomical  Museum  of  the  University  of  Edinburgh  are  several  beautiful 
injections  of  uteri  with  fibrous  tumors  connected  to  them.  Vessels  of  some  size  may  be 
seen  ramifying  beneath  the  peritoneal  coat  of  the  tumors,  and  13'ing  in  the  laxer  areolar 
partitions  between  the  lobules  of  more  compact  fibres.  But  the  compact  tissue  itself  is 
comparatively  pale,  and  the  entire  substance  of  the  tumors  exhibits  a  much  smaller  amount 
of  vascularity  than  the  uteri,  to  which  they  are  connected. 

f  Some  of  the  best  examinations  are  by  Valentin,  in  his  Repertorium ;  and  by  Bidder,  in 
Walter,  Ueber  fibrose  Korper  der  Gebarmutter,  p.  37. 

J  Fig.  55.  Minute  structure  of  a  uterine  fibrous  tumor.  Narrow  smooth  muscular  fibres 
project  from  the  edges  of  a  fibrous  tissue.     Magnified  about  400  times. 

§  The  identity  of  structure  between  these  tumors  and  the  uterus  itself  is  further  proved 
by  the  interesting  observations  of  Dr.  Bristowe  (Trans.  Path.  Soc,  vol.  iv,  p.  216).  He 
found  that  during  pregnancy  the  tumors  both  grew  and  developed  perfect  smooth  muscular 
fibres  "  identical  in  size,  shape,  general  appearance  and  arrangement  with  those  of  the 
uterine  parietes."  Dr.  Oldham  has  also  noticed  (Guy's  Hospital  Reports,  Ser.  ii,  vol.  viii), 
that  after  parturition  tumors  of  great  size  may  shrink,  like  the  uterus  itself. 

28 


426  FIBRO-CYSTIC    TUMORS. 

the  tissue  of  the  uterus,  is  usual,  if  not  constant,  in  these  tumors.* 
(Fig.  55.) 

In  the  subcutaneous  fibrous  tumors,  and  in  some,  I  believe,  of  the 
uterine  tumors,  also,t  elastic  fibres,  with  all  their  fully  developed 
characters,  may  be  intermingled  with  the  more  abundant  fibrous  tissue. 
The  structure  of  fascia  is  thus  imitated ;  and,  if  we  were  to  call  those 
last  mentioned  "muscular"  tumors,  these  should  be  named  "fascial." 

Again,  in  the  fibrous  tumors  on  bones,  bone,  in  small  plates  or  spicula, 
is  often  present,  or  there  may  be  mixtures  of  fibrous  and  cartilaginous 
tissue.  Possibly,  also,  other  mixtures  of  tissues  may  occur  in  what  we 
commonly  accept  as  fibrous  tumors ;  but  I  suppose  that  a  general  state- 
ment may-  be  truly  made,  to  the  effect  that  the  common  characters  of 
fibrous  tumors,  such  as  I  just  described,  are  usually  modified  towards 
an  imitation  of  tissues  in  or  near  which  they  are  severally  placed. 

Their  structural  homology  is  thus  complete ;  and  I  presume  they  may 
be  equally  similar  in  chemical  properties.  They  yield  gelatine  on 
boiling  ;  but  I  am  not  aware  of  any  examination  of  their  other  consti- 
tuents. 

To  the  varieties  of  the  fibrous  tumor  already  named,  two  must  yet  be 
added,  depending  on  changes  which  we  may  regard  as  results  of  dis- 
ease or  degeneration.  One  consists  in  the  formation  of  cysts,  the  other 
in  the  deposit  of  calcareous  and  other  salts  in  the  substance  of  the 
tumor;  suggesting,  severally,  the  names  of  the  "  fibro-cystic,"  and  the 
"  fibro-calcareous,"  tumor. 

The  formation  of  cysts  is  not  rare  in  fibrous  tumors,  especially  in 
such  as  are  more  than  usually  loose-textured.  It  may  be  due  to  a  local 
softening  and  liquefaction  of  part  of  the  tumor,  with  effusion  of  fluid 
in  the  affected  part ;  or  to  an  accumulation  of  fluid  in  the  interspaces 
of  the  intersecting  bands ;  and  these  are  the  probable  modes  of  forma- 
tion of  the  roughly-bounded  cavities  that  may  be  found  in  uterine  tu- 
mors. But  in  other  cases,  and  especially  in  those  in  which  the  cysts 
are  of  smaller  size,  and  have  smooth  and  polished  internal  surfaces,  it 
is  more  probable  that  their  production  depends  on  a  process  of  cyst- 
formation,  corresponding  with  that  traced  in  the  cystic  disease  of  the 
breast  and  other  organs.     The  whole  subject,  however,  relating  to  the 

*  Professor  FCrster  has,  in  Virchow's  Archiv,  vol.  xiii,  p.  270,  1 858,  pointed  out  that,  in  an 
example  of  that  very  rare  form  of  "fibroid'' tumor,  which  grovs^s  in  connection  with  the 
muscular  coat  of  the  intestine,  the  structure  consisted,  besides  the  bundles  of  fibrous  tissue, 
of  numerous  non-striped  muscular  fibres,  which,  just  as  in  fibrous  tumors  of  the  uterus,  were 
arranged  in  larger  and  smaller  bundles,  crossing  each  other.  The  tumor  was  so  closely 
connected  to  the  muscular  coat  of  the  ileum,  that  it  could  not  be  removed  without  injury  to 
the  latter.  The  name  Myoma  has  been  proposed  by  Forster  and  Virchow,  to  distinguish 
these  tumors,  in  which  the  fiat  muscular  fibres  occur  so  abundantly,  from  the  ordinary 
fi.brous  tumors,  formed  only  of  connective  tissue. 

f  See  Bidder,  in  Walter,  1.  c,  p.  38.  I  have  found,  also,  in  a  subperitoneal  fibrous 
tumor  in  the  stomach,  elastic  fibres  just  corresponding  with  those  of  the  natural  subperito- 
neal tissue. 


FIBRO-CYSTIC    TUMORS.  427 

origin  of  the  cysts,  needs  further  consideration ;  and  I  will  speak  only 
of  the  general  appearance  of  the  fibro-cystic  tumors. 

First,  then,  we  find  examples  of  fibrous  tumors  thickly  beset  with 
numerous  well-defined  and  lined  cysts.  This  appears  to  be  the  nature 
of  the  "hydatid  testis"  described  by  Sir  Astley  Cooper.  The  speci- 
mens that  I  have  seen  of  it  make  me  think  that  it  is,  essentially,  a 
fibrous  or  fibrous  and  cartilaginous  tumor  in  the  testicle,  with  more  or 
less  of  cyst-formation  in  the  tumor.  For,  upon  or  around  the  tumor, 
the  seminal  tubes  or  their  remains  may  be  traced  outspread  in  a  thin 
layer,  and  without  difficulty  separable  ;  and  the  substance  of  the  tumor 
is  a  distinct  mass  of  common  fibrous  tissue  with  or  without  imbedded 
nodules  of  cartilage,  and  with  a  variable  number  of  imbedded  cysts, 
filled  with  pellucid  serous  or  viscid  contents.*  A  similar  condition  may 
be  found,  but  is  rare,  in  fibrous  tumors  of  the  uterus.  It  may  be  found 
also,  I  believe,  in  fibrous  tumors  in  nerves  and  other  parts. 

In  another  set  of  cases,  we  find  one  large  cyst  existing  alone,  or  far 
predominating  over  all  the  others,  in  a  fibrous  tumor.  This  is  most 
frequent  in  the  tumors  in  the  nerves,f  and  in  the  uterus.  In  the  latter 
organ  it  has  peculiar  interest,  because  the  cyst,  if  it  attain  a  great  size, 
may  be  mistaken  and  treated  for  an  ovarian  cyst.  Several  such  cases 
have  happened.  The  preparation  from  one  is  in  the  Museum  of  the 
College  (No.  2657) ;  the  history  of  which,  sent  by  Sir  Everard  Home, 
is,  that  it  is  "A  portion  of  a  uterus,  in  which  a  very  large  encysted 
tumor  had  formed.  The  patient  had  been  twice  tapped,  and  the  cyst 
emptied.  The  case  was  supposed  to  be  an  ovarian  dropsy  during  life." 
In  another  case,  Mr.  Caesar  Hawkins,  suspecting  ovarian  disease,  drew 
fifteen  pints  of  fluid  from  a  great  cyst  in  a  fibrous  tumor  of  the  uterus. | 
The  patient  died  a  long  time  afterwards,  and  the  specimen,  which  is  in 
the  Museum  of  St.  George's  Hospital,  shows  an  enormous  fibrous  tumor 
in  the  side-wall  of  the  uterus,  having  one  vast  cavity,  and  in  its  solid 
part  many  small  cysts. 

With  regard  to  the  fibro-calcareous  tumor,  it  is  to  be  observed  that 
two  methods  of  calcification  exist ;  a  peripheral,  and  an  interstitial.  In 
the  former,  which  is  the  rarer,  an  ordinary  fibrous  tumor  is  coated  with 

*  The  results  of  Mr.  Curling's  "Observations  on  Cystic  Disease  of  the  Testicle"  (Med. 
Chir.  Trans.,  vol.  xxxvi,  1853)  prove,  that  in  the  cases  of  fibrocystic  tumor  he  examined, 
the  cysts  were  formed  of  dilated  portions  of  the  seminal  ducts.  They  w^ere  lined  with  tes- 
sellated epithelium,  the  cartilaginous  and  other  growths  which  these  tumors  sometimes  con- 
tained being  formed  within  these  dilated  ducts.  Billroth's  observations  (Virchow's  Archiv, 
viii,  1855)  also  add  to  the  probability  of  these  cystic  growths  in  fibrous  tumors  of  the  tes- 
ticle being  due  to  morbid  states  of  the  seminal  tubes  themselves,  or  of  gland-like  growths 
from  them. 

■{■  See  Smith  on  Neuroma,  p   6. 

X  Medical  Gazette,  vol.  xxxvii,  p.  1022.  This  specimen  and  others  are  described  by  Mr. 
Prescott  Hewett  in  the  London  Journal  of  Medicine.  See,  also,  on  suppuration  in  these 
cysts,  Dr.  Robert  Lee,  in  the  Med. -Chir.  Trans.,  vol.  xxxiii.  Two  remarkable  cases  of  the 
same  kind  are  related  by  Schuh  (Pseudoplasmen,  p.  165).  In  one  of  them  the  huge  cyst 
in  the  uterine  tumor  produced  the  greatest  enlargement  of  the  abdomen  that  he  ever  saw. 


428 


FIBRO-CALCAREOUS    TUMORS. 


Fig.  56.  t 


a  thin,  rough,  nodulated  layer  of  chalky  or  hone-like  substance.*  In 
the  latter  method,  a  similar  substance  is  deposited  more  abundantly 
throughout  the  tumor,  aiid  is  usually  so  arranged,  that,  by  maceration, 
one  obtains  a  heavy  hard  mass,  variously  knotted  and  branched  like  a 
lump  of  hard  coral.  Such  a  specimen  is  in  the  College  Museum  (No. 
226) :  it  was  found  in  a  graveyard,  and  was  sent  to  Mr.  Hunter  as  a 
urinary  calculus.  It  is  an  oval  coral-like  mass,  about  five  inches  long. 
On  analysis,  it  yielded  18-644  per  cent,  of  animal  matter,  consisting  of 
gelatine,  with  a  small  proportion  of  albumen ;  and  its  other  chief  con- 
stituents were  found  to  be  phosphate  and  carbonate  of  lime,  the  pro- 
portion of  carbonate  being  greater  than  in  human  bone. 

A  similar,  but  larger,  specimen  is  in  the  Museum  of  St.  George's 
Hospital ;  and  one  yet  larger  in  that  of  the  Middlesex  Hospital,  which 
has  been  described,  with  a  history  full  of  interest,  by  Mr.  Arnott.f 
Now  the  change  which  ensues  in  these  cases  is  not  ossification  ;  true 
bone,  I  believe,  is  not  formed  in  the  fibrous 
tumors  of  the  uterus.  The  change  is  a  cal- 
careous degeneration,  consisting  in  an  amor- 
phous and  disorderly  deposit  of  salts  of  lime 
and  other  bases  in  combination  with,  or  in 
the  place  of,  the  fibrous  tissue.  §  It  is  repre- 
sented, from  Dusseau's  plate,  in  the  adjacent 
figure  (Fig.  56).  The  process  is  important, 
as  being  the  manifestation  of  a  loss  of  for- 
mative power  in  the  tumor.  The  calcified 
fibrous  tumors  probably  never  grow,  and  are 
as  inactive  as  the  calcified  arteries  of  old 
age.  1 1 

With  these  degenerations  I  may  mention 
(though  it  has  probably  more  of  the  nature 
of  a  disease)  a  softening  of  fibrous  tumors, 
in  which,  quickly,  and  apparently  in  connec- 
tion, with  increased  vascularity  and  conges- 
tion they  become  oedematous,  and  then,  as 
their  tissue  loosens,  become  very  soft,  or  even  diffluent,  or  else  break 
up,  and  appear  shreddy  and  fiocculent.     In  this  state  the   outer  and 


*  As  in  Mus.  Coll.  Surg.,  No.  2670. 

f  Calcareous  deposit  in  a  fibrous  uterine  tumor :  copied  from  Dusseau. 

X  Medico-Chirargical  Transactions,  vol.  xxiii,  p.  199.  In  the  Anatomical  Museum  of  the 
University  of  Edinburgh  is  a  section  of  one  of  these  calcareous  degenerated  fibrous  tumors. 
From  its  extreme  hardness  and  compactness,  it  looks  almost  like  a  mass  of  ivory.  In  its 
entire  state  it  weighed  5  lbs. 

§  On  the  appearance  of  a  crystalline  form  in  the  deposits,  see  Dusseau  (Onderz.  van  het 
Beenweefsel  en  van  Verbeeningen  in  zachte  Deelen,  p.  80). 

II  A  remarkable  exemplification  is  in  Mr.  Arnott's  case.  In  forty  years,  the  calcified 
tumor  did  not  more  than  double  its  size. 


FIBRO-CALCAREOUS     TUMORS.  429 

less   softened  part  of  the  tumor  may  burst,  or  they  may  separate  or 
slough.* 

The  most  frequent  seat  of  fibrous  tumors  is,  beyond  all  comparison, 
in  the  uterus.  Indeed,  we  may  hold  that  the  fibrous  uterine  tumors 
are  the  most  frequent  of  all  innocent  tumors,  if  Bayle's  estimate  be 
nearly  true,  that  they  are  to  be  found  in  20  per  cent,  of  the  women  who 
die  after  thirty-five  years  of  age.  But  I  shall  not  dwell  on  the  fibrous 
tumors  in  the  uterus,  fully  described  as  they  are  by  Dr.  Robert  Lee, 
and  other  writers  on  uterine  pathology.  I  will  only  say,  that  such  tu- 
mors may  occur  near,  as  well  as  in,  the  uterus  ;  but  that,  in  respect  of 
this  nearness,  they  are  probably  limited  to  those  parts  in  which  fibrous 
and  smooth  muscular  tissue,  like  that  of  the  uterus,  extends  ;  namely, 
to  such  parts  as  the  utero-rectal  and  utero-vesical  folds,  and  the  broad 
ligaments. t 

l^ext  to  the  uterus,  the  nerves  are  the  most  frequent  seats  of  fibrous 
tumors.  But  of  these,  while  I  can  refer  to  the  splendid  monograph  by 
Dr.  Smith,|  I  will  say  only  that,  among  the  neuromata,  the  fibrous  tu- 
mors reach  their  climax  of  multiplicity,  existing  sometimes  in  every 
considerable  nerve  of  the  body,  and  amounting  to  1200  or  more  in  the 
same  person. § 

So,  too,  having  in  view  only  the  general  pathology  of  tumors,  and 
not  the  study  of  their  local  relations  or  efi"ects,  I  will  but  briefly  men- 
tion the  fibrous  tumors  of  bones  ;  referring  for  a  larger  account  of  these 
to  Mr.  Stanley's  Treatise  on  the  Diseases  of  the  Bones,  and  to  Mr. 
Caesar  Hawkins's  Lectures  on  their  Tumors. || 

*  The  whole  of  this  process  is  extremely  well  described  in  Dr.  Humphry's  Lectures  on 
Surgery;  Lect.  xxvii,  p.  139.  Lately  I  have  found  imbedded  in  a  large  pendulous  fibrous 
uterine  tumor,  a  distinct  circumscribed  fatty  tumor,  as  large  as  a  walnut,  Mas.  St.  Earth. 
Fibrous  tumors  would  also  appear  to  undergo  distinct  fatty  degeneration.  In  a  specimen 
which  had  been  removed  from  over  the  left  tibia,  examined  some  time  ago  by  the  editor, 
the  part  of  the  tumor  next  the  cutaneous  surface  was  in  a  great  measure  converted  into  a 
yellow  mass,  composed  of  fatty  granules.  And  in  the  deeper  part  of  the  tumor  in  which 
the  fibrous  structure  was  still  preserved,  distinct  yellow  lines,  consisting  of  rows  of  fatty 
granules,  could  be  seen.  These  appeared  to  correspond  in  their  position  to,  and  consist  of, 
the  degenerated  corpuscles  of  the  connective  tissue. 

f  It  appears,  indeed,  to  be  this  mixed  tissue  to  which  the  fibrous  tumors  particularly 
attach  themselves  ;  for  they  are  in  close  relation  with  it  in  other  parts  besides  the  uterus ; 
e.  ff.  in  the  skin  and  the  submucous  tissue  of  the  digestive  canal  and  other  parts. 

J  On  Neuroma :  folio.  Numerous  cases  are  also  collected  by  Moleschott  in  the  Neder- 
landsch  Lancet,  Nov.,  1845,  and  by  Kupferberg :  Beitrag  zur  Geschwiilste  im  Verlaufe  der 
Nerven,  Mainz,  1854. 

§  M.  Lebert  has  related  a  case  (Comptes  Rendus  de  la  Soc.  de  Biologie,  t.  i,  p.  .3)  of  a 
woman,  sixty-six  years  old,  who  had  several  hundreds  of  fibrous  tumors  in  different  parts  of 
her  subcutaneous  tissue.  But  these  do  not  seem  to  have  been  connected  with  nerves.  A 
case  is  related  by  Luschka  in  Virchow's  Archiv,  b.  viii,  p.  343.  185-5,  in  which  a  fibrous  tu- 
mor as  large  as  a  small  hen's  egg,  and  completely  isolable,  was  imbedded  in  the  heart  of  a 
child  six  years  old. 

II   Medical  Gazette,  vols,  xxi-ii-v. 


430  SUBCUTANEOUS    FIBROUS    TUMORS. 

Leaving  these  instances  of  fibrous  tumors,  the  histories  of  which  have 
been  so  fully  written,  I  will  select,  for  the  general  illustration  of  the 
whole  group,  some  that  are  less  generally  studied ;  especially  those 
that  are  found  in  the  subcutaneous  tissue,  and  deeply  seated  near  the 
periosteum,  or  other  fibrous  and  tendinous  structures. 

The  subcutaneous  fibrous  tumors^  to  ^^hich  those  of  the  submucous 
tissue  closely  correspond,  pass,  as  I  have  already  said  (p.  407),  within 
sensible  gradations  into  the  fibro-cellular.  Many  may  be  found  that 
might  deserve  either  name,  just  as  there  are  many  examples  of  natural 
tissues  with  the  same  intermediate  characters ;  but  it  is  not  very  rare 
to  find  specimens  with  all  the  distinctive  features  ascribed  to  the  fibrous 
tumors  of -the  uterus.  These  form  firm,  nearly  hard,  and  tense,  round 
or  oval  masses,  imbedded,  single  or  numerously,  in  the  subcutaneous 
fat,  raising  and  thinning  the  cutis.  They  may  here  attain  an  immense 
size,  as  in  a  case  from  the  Museum  of  Mr.  Liston.*  A  tumor,  weighing 
upwards  of  twelve  pounds,  was  removed  from  the  front  of  a  man's  neck, 
together  with  a  portion  of  the  integuments  and  platysma  that  covered 
it.  It  was  fifteen  years  in  progress,  and  has  an  aspect  such  as,  I 
think,  belongs  only  to  a  fibrous  tumor.  Specimens,  however,  of  this 
size  are  very  rare ;  they  are  commonly  removed  while  less  than  an  inch 
in  diameter. 

In  microscopic  characters  the  subcutaneous  fibrous  tumors  have  the 
general  properties  of  the  species,  but  they  commonly  contain  elastic 
tissue,  and  they  are  apt,  I  think,  to  be  lowly  developed,  having  only  a 
fibrous  appearance,  or  even  seeming  composed  of  a  uniform  blastema, 
with  imbedded  elongated  nuclei,  like  the  material  for  the  formation  of 
new  tendons. 

A  peculiar  and  important  character  in  these  fibrous  tumors  is,  that 
though  they  may  be  completely  isolated  in  every  other  part,  they  often 
adhere  closely  to  the  lower  surface  of  the  cutis,  and  that,  if  in  any  de- 
gree irritated,  they  soon  protrude  through  it,  and  form  vascular  masses, 
"fungous  growths,"  as  they  are  called.  When  this  happens,  they 
may  bleed  profusely,  and  in  a  manner  which,  I  believe,  is  not  imitated 
by  any  other  innocent  tumor, 

A  woman,  52  years  old,  was  under  Mr.  Stanley's  care  with  a  tumor 
that  projected  through  the  integuments  in  the  inner  part  of  the  thigh, 
its  base  being  imbedded  deep  in  the  subcutaneous  tissue,  and  its  pro- 
truding surface  raw  and  ulcerated.  The  origin  of  this  tumor  was  uncer- 
tain, but  it  had  existed  more  than  nine  years ;  it  had  grown  quickly, 
and  had  began  to  protrude  within  two  and  a  half  years.  From  its  ul- 
cerated surface  hemorrhage  frequently  ensued;  and  the  patient  stated 
that  at  one  time  two  quarts  of  blood  flowed  from  it.  The  tumor  was 
excised,  and  large  vessels  that  entered  its  base  bled  freely  in  the  opera- 

*  Mus.  Coll.  Surg.,  222. 


DEEP-SEATED    FIBROUS    TUMORS.  431 

tion.     It  appeared  to  be  a  well-marked  specimen  of  a  soft  and  loAvly- 
developed  fibrous  tumor. 

A  similar  case  was  under  my  care  in  a  woman  27  years  old.  The 
tumor,  of  three  years'  growth,  and  protruding  over  the  front  of  the 
tibia,  was  similarly  ulcerated,  and  used  often  to  bleed ;  sometimes  it 
bled  largely,  and  once  as  much  as  half  a  pint  of  blood' flowed  from  it. 
This  also,  on  removal,  appeared  to  be  a  fibrous  tumor. 

Through  the  kindness  of  Mr.  Birkett,  I  saw  a  specimen,  from  a  much 
more  formidable  example,  of  the  same  fact.  A  woman,  60  years  old, 
had  a  large  pendulous  tumor  in  the  front  wall  of  her  abdomen,  suspended 
just  below  the  umbilicus,  and  reaching  half  way  to  her  knees.  Its 
surface  had  a  very  inflamed  appearance,  and  the  separation  of  a  slough 
from  its  posterior  part  gave  issue  to  such  hemorrhage  as  proved  quickly 
fatal. 

The  tumor  is  a  large,  heavy  mass,  which  was  attached  to  the  sheath 
of  the  rectus.  It  is  everywhere  firm  and  tough,  except  where  its  sub- 
stance appears  to  have  been  broken  by  blood  issuing  from  numerous 
large  vessels  that  traverse  it.  Mr.  Birkett,  who  examined  it  soon  after 
the  patient's  death,  found  its  texture  certainly  fibrous.* 

The  fibrous  tumors  that  occur  in  or  near  accumulated  fibrous  tissues 
are  well  exemplified,  medically,  by  some  of  those  of  the  dura  mater, 
and,  surgically, by  those  which  maybe  found  at  the  tarsus  or  metatarsus, 
imbedded  among  the  ligaments  and  other  deep-seated  parts.  Some 
well-marked  specimens  are  in  the  Museum  of  the  College.  One,t  from 
the  collection  of  Mr.  Langstafi",  is  an  oval  tumor,  six  inches  long, 
fixed  to  the  periosteum  of  the  tarsal  bones  and  to  the  adjacent  parts, 
and  filling:  the  sole  of  the  foot  from  the  os  calcis  to  the  bases  of  the  first 
phalanges.  It  was  removed,  with  the  foot,  from  a  nobleman,  35  years 
old,  in  whom  it  had  been  observed  gradually  increasing  for  thirty  years. 
It  has  all  the  general  aspects  of  the  fibrous  tumor,  as  typified  in  those 
of  the  uterus. 

A  very  similar  specimen  is  shown  in  a  tumor  growing  over  the  whole 
length  of  the  dorsal  aspect  of  the  metatarsus ;%  and  with  these  may  be 
mentioned  one§  which  has  some  historic  interest,  for  it  was  removed 
from  the  Hon.  William  Wyndham,  the  associate  and  friend  of  Pitt,  and 
Fox,  and  Burke, — "  the  model  of  the  true  English  gentleman."  When 
he  was  60  years  old,  and  an  invalid,  he  exerted  himself  very  actively 
one  night  in  saving  from  fire  the  library  of  a  friend.  During  his  exer- 
tions he  fell,  and  struck  his  hip ;  and  from  that  injury  the  tumor  ap- 
peared to  derive  its  origin.  It  grew  quickly,  and  in  ten  months  it  seemed 
necessary  to  remove  it.  Mr.  Wyndham  submitted  to  the  operation,  his 
biographer  says,  "  with  neither  hope  n'or  fear  ;"  and  it  would  be  difiicult 

*  This  specimen  was  sent  to  the  Museum  of  Guy's  Hospital  by  Mr.  Nason. 
f  No.  220.     The  other  half  of  the  same  is  in  the  Museum  of  St.  Bartholomew's  Hospital, 
Series  xxxv,  No.  9. 

X  Mus.  Coll.  Surg.,  219.  §  Mus.  Coll.  Surg.,  218. 


432 


FIBROUS    TUMORS     ON    BONE    AND     PERIOSTEUM. 


to  describe  so  briefly  a  raore  unfavorable  state  of  mind.      The  operation 
was  performed  by  Mr.  Lynn.     The  tumor  was  attached  to  the  capsule 

of  the  hip,  and  was  with  difficulty 
Fig.  57.*  removed.    At  fl.rst  all  went  on  well ; 

but  then,    it   is    said,   symptomatic 
fever  came  on,  and  death  occurred 
on  the  sixteenth  day.     The  tumor 
was,  by   Mr.    Wyndham's   request, 
placed  in  the  Museum  of  this  Col- 
lege; and  I  have  had  it  sketched, 
because  it  might  be   signalized  as 
one  of  the  most  characteristic  ex- 
^      amples  of  its  kind. 
\\^         I  might  add  several  to  these  cases, 
|l    but   these   may  suffice  for  illustra- 
"     tions  of  the  fibrous  tum.ors  connected 
with  the  deep-seated  fibrous  tissues. 
M    All  the  specimens  that  I  have  seen 
"'       have    presented    the    strong    white 
bands  intersecting  a  grayish  or  dull 
white    basis-substance,    the   charac- 
teristic firmness,  heaviness,  and  ten- 
sion;  all,  in  microscopic   examina- 
tion, have  shown  the  tough  fibrous  structure  or  appearance ;   all  have 
yielded  gelatine  in  boiling. 

The  favorite  seats  of  the  fibrous  tumors  of  bone  and  periosteum  are 
about  the  jaws  ;  on  other  bones  they  are  very  rare.  The  College  Mu- 
seum is,  I  suppose,  eminently  rich  in  fibrous  tumors  connected  with  the 
jaws,  containing  as  it  does  the  chief  of  those  that  were  removed  by  Mr. 
Liston;  a  series  illustrative  at  once  of  his  admirable  dexterity,  and  of 
his  sound  knowledge  of  pathology. 

These  tumors  of  the  jaws  may,  to  both  touch  and  sight,  present  the 
ordinary  characters  of  the  fibrous  tumors,  as  already  described.  They 
usually  approach  the  round  or  oval  shape,  but  are  generally  knobbed, 
or  superficially  lobed,  or  botryoidal,  as  some  have  called  them.  They 
are  firm,  dense,  and  heavy.  On  section,  however,  the  majority  of  them, 
I  think,  are  more  uniform  than  the  fibrous  tumors  of  other  parts.  They 
are  generally  almost  uniformly  white,  and  scarcely  intersected  by  any 
distinct  fibrous  bands,  except  such  as  may  divide  them  into  lobes. 
Many  of  them  also  present,  in  their  interior,  minute  spicula  of  compact, 
white,  bony  texture. 

As  to  situation  and  connection,  the  fibrous  tumors  of  the  jaws  may 
be  found  isolated  and  circumscribed,  growing  within  the  jaw,  divorcing 


*  Fig.  57.     Section  of  a  deep-seated  fibrous  tumor;  from  the  case  described  in  the  text. 
Natural  size. 


FIBROUS    TUMORS     ON    BONE    AND    PERIOSTEUM. 


433 


and  expanding  its  walls,  and  capable  of  enucleation*  (Fig.  58  a)  ;  but, 
in  a  large  number  of  these  tumors,  the  periosteum,  with  or  without  the 
bone  itself,  is  involved  or  included  in  the  outgrowing  mass  (Fig.  58  b). 

Fig.  58.t 


The  diflFerence  is  illustrated  by  the  sketches  (Fig.  58).  In  the  case  of 
the  upper  jaw,  either  the  periosteum,  or  the  fibro-mucous  membrane  of 
the  antrum  or  nasal  walls,  or  both  of  these,  may  be  included  in  such  a 
tumor.  In  all  cases  the  tumor  lies  close  upon  the  bone,  and  cannot  be 
cleanly  or  without  damage  to  it  separated,  except  on  the  outer  surface : 
commonly,  indeed,  bony  growths  extend  from  the  involved  bone  into 
the  tumor ;  and  sometimes  the  greater  part  of  the  bone  is  as  if  broken 
up  in  the  substance  of  the  tumor. 

In  all  these  characters  of  connection,  the  fibrous  tumors  on  the  ex- 
terior of  the  jaws  and  about  other  bones  resemble  outgrowths  :  they  are 
as  if  some  limited  portion  of  the  periosteum  were  grown  into  a  tumor 
overlying  or  surrounding  the  bone.  The  character  of  outgrowth  is  in- 
deed generally  recognized  in  the  epulis,  or  tumor  of  the  gums  and 
alveoli ;  but  I  believe  Mr.  Hawkins  is  quite  right  in  the  view  which  he 
has  expressed,  that  the  fibrous  epulis  should  be  regarded  as  a  tumor 
growing,  like  most  of  the  other  fibrous  tumors,  from  the  bone  and  peri- 
osteum, and  continuous  with  them.|     That  it  is  prominent  and  lobed 

*  For  such  cases  see  the  Museums  of  the  College  and  of  St.  Bartholomew's  and  Guy's 
Hospitals;  Stanley,  Illustrations,  pi.  16,  Fig.  8;  Ward,  Proc.  of  the  Pathol.  Soc,  Nov.  16, 1846. 

t  Fig.  58  A.  Fibrous  tumor  within  the  ramus  of  the  lower  jaw,  disparting  and  extend- 
ing its  walls.  B.  A  similar  tumor  outgrowing  upon  the  lower  jaw.  Both  are  represented 
in  section,  one  half  of  the  natural  size,  from  specimens  at  St.  Bartholomew's.  Both  con- 
sisted of  perfect  and  unmixed  fibrous  tissue. 

J  I  say  fibrous  epulis^  because  growths  may  be  found  resembling  common  epulis  in  many 
characters,  yet  differing  in  some,  and  especially  in  microscopic  structure.  M.  Lebert  classes 
epulis  with  fibro-plastio  tumors,  and  I  shall  refer  in  the  next  lecture  to  specimens  present- 
ing the  structure  to  which  he  gives  that  name  ;  but  more  of  those  which  I  have  examined 
were  of  a  purely  fibrous  texture.  The  difference  may  be  important  in  surgery;  for  there  is 
always  uncertainty  about  the  operations  for  epulis;  perhaps  because  among  the  firm-lobed 
outgrowths  from  the  gums  and  jaws,  to  all  of  vi^hich  the  same  name  is  applied,  there  are 
two  or  more  kinds  of  tumors,  vi'ith  as  many  different  properties.  The  lecture  of  Mr. 
Hawkins  (Medical  Gazette,  vol.  xxxvii,  p.  1022)  is  the  best  study  on  the  subject  of  epulis. 
Mr.  Birkett  tells  me  he  has  found  the  glands  of  the  gum  much  developed  in  some  instances 
of  tumors  thus  nanied. 


434  FIBROUS    TUMORS    IN    THE    EARS. 

is  because  it  grows  into  the  open  cavity  of  the  mouth ;  and  it  resembles 
gum  only  because  it  carries  with  it  or  involves  the  natural  substance  of 
the  gum. 

I  will  refer  to  but  one  more  set  of  cases  of  fibrous  tumors  ;  those, 
namely,  that  occur  in  the  lobules  of  the  ears.  These  are,  indeed,  tri- 
vial things  in  comparison  with  the  tumors  of  the  jaws,  yet  they  have 
points  of  interest,  in  that  they  grow  after  injuries,  and  are  very  apt  to 
recur  after  removal.  They  are  penalties  attached  to  the  barbarism  of 
ear-rings.  Shortly  after  the  lobules  of  the  ears  have  been  pierced,  it 
sometimes  happens  that  considerable  pain  and  swelling  supervene. 
These  are  apt  to  be  followed  by  a  more  defined  swelling  in  the  track  of 
the  puncture  ;  and  this  swelling  presently  becomes  a  well-marked  fibrous 
tumor  in  the  lobule  of  the  ear.  There  may  be,  perhaps,  some  doubt 
whether  the  growth  be  a  proper  tumor  or  a  cheloid  growth  of  the  cica- 
trix-tissue  formed  in  the  track  of  the  wound  ;  but  it  has  the  aspect  of 
a  distinct  fibrous  tumor,  and  the  skin  appears  unafiected. 

In  one  case,  of  which  the  specimens  were  presented  to  the  Museum 
of  St.  Bartholomew's  Hospital*  by  Mr.  Holberton,  a  tumor,  such  as  I 
have  described,  formed  in  the  lobule  of  each  ear  of  a  young  woman,  a 
few  months  after  they  were  pierced  for  ear-rings.  Both  the  lobules  were 
cut  off  with  the  tumors  ;  but,  in  or  beneath  one  of  the  cicatrices,  a  simi- 
lar tumor  formed  shortly  afterwards.  This  was  excised ;  and  in  the 
ten  years  that  have  since  elapsed,  there  has  been  no  return  of  the  dis- 
ease. 

In  another  case,  under  the  care  of  Mr.  Benjamin  Barrow,  two  such 
tumors  formed  in  the  same  ear  after  puncture.  One  of  these  was  cut 
away,  the  other  was  left :  a  third  grew,  and  the  excision  of  the  whole 
lobule  was  necessary  for  the  complete  extirpation  of  the  disease. 

Similar  cases  are  recorded  by  Bruch,f  Venzetta,|  and  others  ;  but 
the  histories  of  the  cases  are  so  like  these  that  I  need  not  detail  them. 

Among  tumors  so  diverse  in  their  seats  and  relations  as  the  fibrous 
tumors,  there  are  perhaps  few  things  relating  to  their  life  that  can  be 
stated  as  generally  true. 

In  the  uterus  many  may  exist  at  the  same  time  :  the  whole  wall  of  a 
uterus  maybe  crammed  with  them,  while  others  project  from  it  into  the 
peritoneal  cavity.  As  Walter  and  others  have  observed,  when  a  fibrous 
tumor  fills  the  cavity  of  the  uterus,  or  projects  from  it  into  the  vagina, 
it  is  not  usual  for  another  to  be  found  in  the  walls.  Such  cases  do  in- 
deed occur,  but  they  are  comparatively  rare.  It  is  yet  much  more 
rare  for  fibrous  tumors  to  be  found  in  any  other  part  at  the  same  time 
as  in  the  uterus.     I  find  but  one  such  case  recorded ;  a  case  by  Dr. 

*  Ser.  XXXV,  No.  24. 

f  Die  Diagnose  der  bosartigen  Geschwiilste,  p.  208. 

J  Annales  de  Chirurgie,  Juillet,  1844. 


CARTILAGINOUS    TUMORS.  435 

Sutherland,*  in  which,  with  several  fibrous  tumors  in  the  uterus,  one 
was  found  in  the  groin  of  a  lunatic  42  years  old.  But  such  a  case  is  a 
most  rare  exception  to  the  rule  ;  or,  indeed,  may  he  more  like  an  ex- 
ample of  the  rule,  if  the  tumor  were  connected  with  the  round  ligament, 
and  the  tissue  therein  continuous  with  the  uterus. 

In  the  nerves,  as  in  the  uterus,  a  multiplicity  of  fibrous  tumors  may 
be  found ;  but,  so  far  as  I  know,  the  rule  of  singleness  generally  pre- 
vails in  every  other  part  liable  to  be  their  seat. 

Their  growth  is  generally  slow  and  painless.  It  is  often  very  slow, 
so  that  tumors  of  thirty  or  more  years'  standing  are  found  still  far 
short  of  the  enormous  dimensions  of  some  of  the  last  species.  But  no 
general  rule  can  be  made  on  this  point,  especially  since  the  rate  of 
growth  is  influenced  by  the  resistance  offered  by  the  more  or  less  yield- 
ing parts  around. 

The  extent  of  growth  appears  unlimited ;  and  among  the  fibrous 
tumors  are  the  heaviest  yet  known.  They  have  weighed  fifty,  sixty, 
and  seventy  pounds.  The  tumor  that  induced  Walter  to  write  his  ad- 
mirable essayf  weighed  seventy-one  pounds.  He  refers,  also,  to  one 
of  seventy-four  pounds,  and  to  one  described  in  an  American  journal 
as  having  been  estimated  at  one  hundred  pounds  ;  but  he  asks  of  this, 
perhaps  impertinently,  whether  it  were  weighed  also  (aber  auch  ge- 
wogen  ?). 

In  relation  to  the  degeneration  and  diseases  of  fibrous  tumors,  I  need 
add  nothing  to  what  has  been  said  concerning  the  formation  of  cysts, 
the  calcification,  and  the  process  of  softening  or  disintegration.  And 
respecting  their  nature,  there  can  be  no  doubt  that,  in  general,  they  are 
completely  innocent. 


LECTURE    XXVI. 


CARTILAGINOUS   TUMORS. 


The  name  of  Cartilaginous  Tumors  may  be  given  to  those  which 
Miiller,  in  one  of  the  most  elaborate  portions  of  his  work  on  Cancer, 
has  named  Enchondroma.J  Either  term  will  sufiiciently  imply  that 
the  growth  is  formed,  mainly,  of  a  tissue  like  cartilage ;  and  I  would  at 
once  point  out  the  singularity  of  such  tumors  being  formed,  and  grow- 
ing to  so  great  a  size  as  I  shall  have  to  describe,  although  cartilage  is 

*  Proceedings  of  the  Pathological  Society,  vol.  ii,  p.  87. 

f  Ueber  fibrose  Korper  der  Gebarmutter.     Dorpat,  4to.,  1842. 

J  Other  names  employed  are  Osteochondroma,  Chondroma,  Benign  Osteo-sarcoma.  The 
term  osteo-sarcoma  cannot  be  too  entirely  disused  ;  it  has  been  more  vague  than  even  Sar- 
coina,  having  been  employed  indiscriminately  for  all  tumors,  of  vi'hatever  nature,  growing 
in  or  upon  bones,  provided  only  they  were  not  entirely  osseous. 


436  CARTILAGINOUS    TUMORS. 

not  commonly  formed  for  the  repair  of  its  own  injuries,  nor,  at  least  in 
man,  in  a  perfect  manner,  for  the  repair  of  the  injuries  of  bone. 

The  cartilaginous  tumors  are  found,  in  the  large  majority  of  cases, 
connected  with  the  bones  and  joints.*  However,  they  occur  not  rarely 
in  soft  parts,  completely  detached  from  bone.  Thus,  in  the  pure  form, 
or  mixed  with  other  tissues,  they  are  met  with  in  the  testicle,f  mammary 
gland,!  subcutaneous  tissue,§  and  lungs,||  and  in  the  soft  parts  near 
bones  ;  but  among  all  the  soft  parts  their  favorite  seat  appears  to  be  the 
neighborhood  of  the  parotid  gland.  The  greater  part  of  the  solid  tumors 
formed  in  this  part  have  cartilage  in  them. 

Cartilaginous  tumors  that  are  connected  with  bones  may,  like  fibrous 
tumors  (Fig.  58),  occur  in  two  distinct  positions ;  namely,  within  the 
walls,  or  between  the  walls  and  the  periosteum :  rarely  they  grow  in 
both  these  positions  at  once.  When  they  are  within  the  bones,  they  are 
isolated  and  discontinuous,  and  are  surrounded  by  the  bone-walls,  which 
may  be  extended  in  a  thin  shell  or  capsule  around  them,  or  may  be 
wasted  and  perforated  by  them:  When  they  grow  outside  the  bones, 
they  are  generally  fastened  to  the  subjacent  bone-wall  by  outgrowths  of 
new  bone  ;  the  periosteum,  greatly  overgrown,  invests  them,  and  pro- 
longations from  it  towards  the  bone  appear  to  intersect  them,  and  divide 
them  into  lobes.  When  they  grow  among  soft  parts,  they  have  a  well- 
formed  connective  tissue  capsule,  which  is  commonly  more  dry  and  glis- 
tening than  that  of  most  innocent  tumors. 

In  any  of  these  situations,  cartilaginous  tumors  may  be  either  simple 
or  complex,  conglobate  or  conglomerate,  if  we  may  adopt  such  terms; 
i.  e.  they  may  be  composed  of  a  single  mass  without  visible  partitions, 
or,  of  numerous  masses  or  knots  clustered,  and  held  together  by  their 
several  investments  of  areolar  tissue.  According  to  these  conditions, 
they  present,  a  less  or  more  knotted  or  knobbed  surface ;  but  in  either 
state  they  affect  the  broadly  oval  or  spheroidal  shape  (Fig.  68). *| 

*  Those  referred  to  as  connected  with  the  joints  are  the  cartilaginous  masses  that  are 
found  pendulous  or  loose  in  joints.  They  have  sufficient  characters  in  common  with  these 
tumors  to  justify  their  enumeration  in  the  list;  yet  they  are  in  so  many  respects  peculiar, 
that  they  need  and  usually  receive  a  separate  history.  The  best  account  of  them,  and  of 
their  probable  origin  in  the  villi  of  synovial  fringes,  may  be  gathered  from  Bidder,  in  Henle 
and  Pfeufer's  Zeitschr.  B.  iii;  Rainey,  in  Proc.  Pathol.  Soc,  ii,  p.  140;  and  KoUiker,  Mik- 
rosk.  Anat.,  ii,  p.  324. 

t  Mus.  Coll.  Surg.,  Nos.  2384-5-6,  &c.  ;  Mus.  St.  Bartholomew's  Hosp.,  Ser.  xxviii,  No.  17, 
and  Appendix ;  and  several  in  the  Museum  of  St.  Thomas's  Hospital.  See  also  Mr.  Gam- 
jee's  pamphlet,  on  a  Case  of  Ossifying  Enchondroma  in  the  Testicle  of  a  horse.  Also  a  case 
related  in  Trans.  Med.  Chi.  Soc,  vol.  xxxviii. 

X  Astley  Cooper,  Diseases  of  the  Breast,  p.  64;  MuUer,  On  Cancer,  p.  149,  No.  13,  from  a 
dog;  Mus.  St.  Bartholomew's,  Ser.  xxxiv.  No.  13,  from  a  bilch. 

^   Rokitansky,  Pathol.  Anat.,  B.  i,  p.  261 ;  Lebert,  Abhandlungen,  p.  195. 

II  Mus.  St.  Bartholomew's,  Pathol.  Appendix;  Rokitansky  and  Lebert,  1.  c.  Forster  in 
Virchow's  Archiv,  vol.  xiii,  p.  106. 

^  In  the  Anatomical  Museum  of  the  University  of  Edinburgh  are  several  very  illustra- 
tive specimens  of  cartilaginous  tumors.  In  most  of  these  the  cartilage  is  arranged  in  the 
form  of  separate  nodules,  varying  in  size  from  a  pea  to  a  bean,  each  nodule  being  invested 


CARTILAGINOUS    TUMORS.  437 

To  the  touch,  cartilaginous  tumors  may  be  very  firm  or  hard,  espe- 
cially when  they  are  not  nodular  and  their  bases  are  ossified.  In  other 
cases,  though  firm,  they  are  compressible,  and  extremely  elastic,  feeling 
like  thick-walled  tensely-filled  sacs.  Many  a  solid  cartilaginous  tumor 
has  been  punctured  in  the  expectation  that  it  would  prove  to  be  a  cyst. 

The  knife  cuts  them  crisply  and  smoothly ;  and  their  cut  surfaces 
present,  in  the  best  examples,  the  characters  of  foetal  cartilage  ;  bright, 
translucent,  grayish,  or  bluish,  or  pinkish-white,  compact,  uniform. 
Usually,  each  separate  mass  or  lobe  is  without  appearance  of  fibrous  or 
other  compound  structure ;  but,  sometimes,  the  cartilage  looks  coarsely 
granular,  as  if  it  were  made  up  of  clustered  granules.  This  is,  I  think, 
especially  the  case  in  the  cartilaginous  tumors  inclosed  in  the  bones  of 
the  hands  and  fingers,  especially  in  such  of  them  as  are  soft.  In  other 
cases,  when  the  cartilage  is  very  firm,  it  may  be  opaque  or  milk-white. 

In  difi'erent  examples  of  cartilaginous  tumor  there  are  great  varieties 
of  consistence  or  firmness.  Some  appear  almost  diffluent,  or  like 
vitreous  humor ;  some  are  like  the  firmest  foetal  cartilage ;  and  all  in- 
termediate gradations  may  be  found  :  but,  with  the  exception  of  the 
cartilaginous  growths  that  are  pendulous  or  loose  in  joints,  I  have  never 
seen  any  present  such  hardness,  dulness,  or  yellowness,  as  do  the  na- 
tural adult  cartilages  of  the  joints,  ribs,  or  larynx. 

As,  in  all  general  appearance,  the  material  of  these  tumors,  in  its 
usual  and  most  normal  conditions,  is  identical  with  foetal  cartilage,  so  is 
it,  I  believe,  in  its  development,  and,  as  Miiller  has  shown,  in  its  che- 
mical characters.*  The  microscopic  characters,  also,  of  cartilaginous 
tumors  agree,  speaking  generally,  with  those  of  foetal  cartilage ;  yet 
there  are  several  particulars  to  be  observed  concerning  them,  and,  espe- 
cially, the  diversity  of  form  and  arrangement  that  may  be  seen  in  the 
microscopic  constituents  of  even  difi'erent  parts  of  the  same  tumor 
needs  mention. 

This  diversity  of  microscopic  forms  is  enough  to  baffle  any  attempt 
to  describe  them  briefly,  or  to  associate  them  with  any  corresponding 
external  characters  in  the  tumors.  The  most  diverse  forms  may  even 
be  seen  side  by  side  in  the  field  of  the  microscope.  But  this  diversity 
is  important.  It  has  its  parallel,  so  far  as  I  know,  in  no  other  innocent 
tumor  ;  and  the  cartilaginous  tumors  form  perhaps  the  single  exception 
to  a  very  generally  true  rule  enunciated  by  Bruch  ;f  namely,  that  it  is 

by  a  loose  capsule  of  connective  tissue.  In  some  of  these  specimens  the  vessels  have  been 
filled  with  a  red  injection,  which  lias  passed  into  the  substance  of  the  tumor,  being  situated 
in  a  distinct,  though  not  very  abundant,  capillary  plexus  lying  in  the  partitions  of  connective 
tissue  between  the  cartilaginous  nodules.  It  was  undoubtedly  from  the  blood  which  circu- 
lated through  these  capillaries,  that  the  nutrition  of  the  tumor  was  effected.  In  the  prepa- 
rations the  red  lines  of  injected  vessels  present  a  striking  contrast  to  the  opaque  white  no- 
dules of  cartilage. 

*  The  enchondromata  of  bones,  he  says,  always  yield  chondrine;  while  those  of  soft 
parts  may  yield  either  gelatine  or  chondrine.  (On  Cancer,  p.  124.)  The  whole  account  of 
their  analysis  is  very  amply  given  by  him. 

f  Die  Diagnose  der  bosartige  Geschwiilste. 


438 


MICROSCOPIC    STRUCTURES 


a  characteristic  of  the  cancerous  tumors,  and  a  distinction  between 
them  and  others,  that  thej  present,  even  in  one  part,  a  multiformity  of 
elementary  shapes. 

The  diversity  of  microscopic  characters  extends  to  every  constituent 
structure  of  the  cartilage  in  the  tumors.  I  will  state  the  general  and 
chief  results  of  the  examinations  of  fifteen  of  the  recent  specimens,* 
of  which  I  have  made  notes,  and  the  drawings  from  which  the  annexed 
figures  were  copied, 

(1)  In  rega,rd,  then,  to  the  basis  or  intercellular  substance :  It  is 
variable  in  quantity,  the  cells  or  nuclei  in  some  specimens  lying  wide 
apart  (Fig.  59),  in  some  closely  crowded  (Fig.  61,  &c.) :    it  varies  in 


Fig.  59.1 


Fig.  eo.j 


consistence,  with  all  the  gradations  to  which  I  have  already  referred ; 
and,  in  texture,  in  some  specimens,  it  is  pellucid,  hyaline,  scarcely 
visible ;    in  some,  dim,  like  glass  breathed   on ;    in  many  more,  it  is 


Fig.  61.  § 


Fig.  62.  !| 


fibrous  in  texture  or  in  appearance 
(Figs.  59,  60).  Most  cartilaginous 
tumors,  indeed,  might  deserve  to  be 
called  fibro-cartilaginous.  It  is  sel- 
dom, and,  I  think,  only  in  the  firmest 

*  These  are  exclusive  of  specimens  of  loose  cartilages  in  joints  ;  of  which,  indeed,  no 
accoiant  will  be  given  in  this  lecture. 

f  Fig.  59.  Tufted,  pale,  filamentous  tissue,  with  a  few  imbedded  cartilage-cells.  From 
a  tumor  over  the  parotid  gland. 

if  Fig.  60.  Stronger  and  denser  fibro-cartilaginous  tissue;  many  of  the  cartilaginous  cells 
having  granulated  nuclei.     From  a  tumor  over  the  parotid  gland,  magnified  400  times. 

§  Fig.  61.  Groups  of  cartilage-cells,  clustered  in  a  portion  of  a  tumor  on  the  phalanx  of 
a  finger.  ]\Iany  of  the  cells  are  only  drawn  in  outline  ;  the  groups  are  intersected  by  bands 
of  tough  fibrous  tissue;  some  of  the  cells  present  double  or  triple  contour-lines^  most  of  the 
nuclei  are  large  and  granular.     Magnified  about  400  times. 

II  Fig.  6-2.  A  group  of  large  cartilage-cells  from  the  same  ;  many  containing  two  or  three 
nuclei,  of  which  some  have  acquired  the  character  of  inclosed  cells. 


or    CARTILAGINOUS    TUMORS. 


439 


parts  or  specimens,  that  the  substance  between  the  cartilage-cells  has 
the  strong  hard-lined  fibrous  texture  which  belongs  to  the  chief  natural 
fibrous  cartilages ;  yet  it  has  generally  a  fibrous  texture.  The  fibres 
are,  or  appear,  usually  soft,  nearly  pellucid,  and  very  delicate ;  some- 
times they  appear  tufted  or  fasciculate  (Fig.  59) ;  sometimes  they 
encircle  spaces  that  contain  each  a  large  cartilage-cell,  or  a  cluster  of 
cells  or  nuclei  (Fig.  61) ;  sometimes  they  form  a  fasciculated  tissue,  in 
which  cartilage-cells  lie  elongated  and  imbedded  (Fig.  60) :  most  com- 
monly of  all,  I  think,  they  curve  among  the  cells,  as  if  they  were 
derived  from  a  fibrous  transformation  of  an  intercellular  hyaline  sub- 
stance (Fig.  63). 


Fig.  63  * 


Fig.  63  A. 


(2)  Yet  greater  varieties  may  be  found  in  the  characters  of  the  car- 
tilage-cells, f  In  plan  of  arrangement  they  may  be  irregularly  and 
widely  scattered,  or  closely  placed,  or  almost  regularly  clustered  with 
fibrous  tissue  encircling  them  (Figs.  59,  61,  62).  In  single  cells  there 
are  varieties  of  size  from  7^oth  to  ysooth  of  an  inch.  And  there  are 
yet  more  varieties  of  shape  ;  some  have  the  typical  form  of  healthy 
preparatory  cartilage-cells,  being  large,  round,  or  oval,  or  variously 
shaped  through  mutual  pressure,  faintly  outlined,  with  single  nuclei, 
and  clear  contents  (Fig.  63) ;  and  some  are  like  normal  compound  car- 
tilage-cells (Fig.  62).  But,  with  various  deviations  from  these  more 
normal  characters,  some  cells  have  hard  dark  outlines ;  and  some  are 
bounded  by  two,  three,  or  four  dotted  or  marked  concentric  circles,  as  if 


*  Fig.  63.  Group  of  cartilage-cells  from  a  tumor  in  the  tibia.  Fine  filamentous  tissue 
encircles,  and  intervenes  between,  single  cells.  Some  of  the  nuclei  of  the  cells  contain  oil- 
particles  ;  and  some  of  the  same  (in  Fig.  63  a)  sliow,  apparently,  the  process  of  assuming  the 
stellate  or  branched  form.     Magnified  about  400  times. 

f  I  retain  this  name,  although  the  observations  of  Bergmann  (De  Cartilaginibus,  1850) 
and  others  show  that  it  is  difficult,  in  some  cases,  to  determine  the  nature  of  the  cell-contents, 
and  that  their  nuclei  may  be  more  like  cells,  or,  having  had  the  characters  and  relations  of 
nuclei,  may  acquire  those  of  included  nucleated  cells.  Taking,  as  the  type  of  cartilage-ceZ^s, 
the  elements  of  the  chorda  dorsalis,  I  think  we  shall  least  often  err  if  we  keep  the  term  cell 
for  those  elementary  structures  in  other  cartilages  which  are  most  like  the  cells  of  the 
chorda,  in  their  fine  clear  outline,  and  the  pellucid  or  dim  space  just  within,  or,  also,  just 
without  it. 


440 


MICROSCOPIC     STRUCTURES. 


Pig.  64.* 


-k 


-fr' 


®    k 


the  cell-walls  had  become  laminated  (Figs.  61,  62) ;  others  appear  with- 
out any  defined  cell-walls,  as 
if    they    were    mere   cavities 
hollowed -out  in  the  basis-sub- 
stance;    and,    in    other    in- 
stances,   the    cell-walls    and 
their   contents,   down   to   the 
nucleus,    appear    as    if    they 
were  completely   fused   with 
the   basis-substance,    so    that 
the  nuclei  alone  appear  to  be 
imbedded  in  the  hyaline  or  dimly  fibrous  material.    These  last  two  states 
appear  to  be  connected  with  very  imperfect  development  or  with  degene- 
ration;   for    I    have    seen 
^ig-  ^-^-t  them,  I  think,  in  only  soft 

cartilage,  or  in  such  as 
showed  other  distinct  signs 
of  degeneration.  In  many 
such  cases,  also,  the  nuclei 
are  so  loosely  connected 
with  the  basis-substance, 
that  large  numbers  of  them 
float  free  in  the  field  of  the 
microscope. 

(3)  The  varieties  of  the  nuclei  in  the  cartilage  of  tumors  are  not  less 
than  those  of  the  cells.  Some  are  like  those  of  the  normal  cartilage  ; 
round  or  oval,  clear,  distinctly  outlined,  with  one  or  two  nucleoli  (Fig. 
62).  But  some  appear  wrinkled  or  collapsed,  as  if  shrivelled ;  some 
contain  numerous  minute  oil-particles,  representing  all  the  stages  to 
complete  fatty  degeneration,  and  the  formation  of  granular  bodies  (Figs. 
60,  63) ;  some  are  uniformly  but  palely  granular,  like  large  pale  cor- 
puscles of  lymph  or  blood  ;  some  are  yet  larger,  nearly  filling  the  cells, 
pellucid,  like  large  clear  vesicles  with  one  or  more  oil-particles  inclosed  ; 
and  some  have  irregularities  of  outline,  which  are  the  first  in  a  series 
of  gradational  forms,  at  the  other  extremity  of  which  are  various  stel- 
late, branched,  or  spicate  corpuscles  (Figs.  63  A,  64,  65). 

I  have  not  been  able  to  discern  any  constant  rule  of  coincidence  be- 
tween these  forms  of  nuclei  and  the  various  forms  of  cells,  nor  between 
either  and  any  of  the  enumerated  appearances  of  the  intercellular  or 
basis-substance.  All  modes  of  combinations  have  appeared  among 
them ;   only,  on  the  whole,  the   completely  developed  cells  have  the 


*  Fig.  64.  Free  nuclei :  some  simple,  and  some  enlarged,  and  variously  beset  with 
branching  processes.  From  a  cartilaginous  tumor  under  the  angle  of  the  lower  jaw.  Mag- 
nified 400  times. 

■j"  Fig.  65.  Similar  nuclei  variously  distorted  and  shrivelled.  From  a  mixed  cartilaginous 
tumor  over  the  parotid  ;  similarly  magnified. 


CARTILAaiNOUS    TUMORS.  441 

best  nuclei,  and  the   degenerate   or  imperfect  of  both  are  usually  in 
company. 

The  last-named  nuclei,  with  irregular  outlines,  deserve  a  more  par- 
ticular description,  both  because  they  are,  so  far  as  I  know,  found  in 
no  normal  cartilage  in  any  of  the  vertebrata,  and  because  their  imita- 
ting, in  some  measure,  the  forms  of  bone-corpuscles,  might  wrongly 
suggest  that  they  have  a  constant  relation  to  the  ossifying  process. 

They  were  first  described,  I  think,  by  Miiller ;  and  have  since  been 
noticed  in  cartilaginous  tumors  by  Mr.  Quekett,  and  many  others.  I 
have  examined  them  in  seven  cases ;  and,  to  show  that  they  are  not 
peculiar  to  one  form  of  cartilaginous  tumor,  I  may  add  that,  of  these 
seven,  one  was  a  great  tumor  encircling  the  upper  part  of  the  tibia,  one 
a  growth  on  the  last  phalanx  of  the  great  toe,  one  a  mixed  tumor  in 
the  articular  end  of  the  fibula,  one  a  very  soft  tumor  in  the  subcutane- 
ous tissue  on  the  chest,  and  three  were  mixed  tumors  over  the  parotid 
or  submaxillary  gland. 

The  phases  of  the  transformation  by  which  they  are  produced  appear 
to  be,  as  represented  in  Figs.  63  a,  64,  65,  that  a  nucleus  of  ordinary 
form,  or  with  one  or  more  oil-particles,  enlarges  and  extends  itself  in 
one  or  several  slender,  hollow,  and  crooked  processes,  which  diverge, 
and  sometimes  branch  as  they  diverge,  towards  the  circumference  of 
the  cell.  Such  nuclei  may  be  found  within  the  cells  (Fig.  63  a),  or 
within  cavities  representing  cells  whose  walls  are  fused  with  the  inter- 
cellular substance ;  but  much  more  commonly  it  appears  as  if,  while 
the  nuclei  changed  their  forms,  the  cells  and  the  rest  of  their  contents 
were  completely  fused  with  the  intercellular  or  basis-substance,  so  that 
the  nuclei  alone  appear  imbedded  in  the  hyaline  or  pale  fibrous  sub- 
stance. The  nuclei  thus  enlarged  may  appear  like  cells,  and  their 
nucleoli  may  be  like  nuclei.  But  although,  at  first,  as  we  may  sup- 
pose, the  nuclei,  as  they  send  out  their  processes,  may  enlarge  and 
retain  the  round  or  oval  form  of  their  central  parts  or  bodies,  yet  they 
afterwards  lengthen  and  attenuate  themselves,  so  as  to  imitate  very 
closely  the  shapes  of  large  bone-corpuscles  or  lacunae  ;  or  they  elongate 
and  branch,  or  shrivel  up ;  and  in  these  states,  lying  in  groups,  they 
have  the  most  fantastic  appearances  (Figs.  64,  65).  In  these  various 
states  the  nuclei  are  often  loosely  connected  with  the  basis-substance ; 
so  that  they  are  easily  removed  from  it,  or  are  found  floating  on  the 
field  of  the  microscope,  as  nearly  all  those  were  which  are  here  drawn. 

Now,  as  I  have  said,  corpuscles  like  these  exist  permanently  in  no 
normal  cartilage  yet  examined,  in  man  or  any  of  the  vertebrata.*  If, 
then,  heterology  of  structure  were  indicative  of  malignancy,  the  tumors 
that  contain  these  corpuscles   should  be   malignant ;  but  there  are  no 

*  The  only  natural  cartilage  yet  known  as  possessing  these  corpuscles  is,  I  believe,  that 
of  the  cuttle-fish  (Quekett,  in  Histol.  Catal.  of  Coll.  of  Surg.,  pi.  Ti,  Fig.  7) ;  and  it  is  at  least 
interesting,  and  may  be  importantly  suggestive,  to  observe  that  the  morbid  structure,  devia- 
ting from  what  is  natural  in  its  own  species,  conforms  with  that  of  a  much  lower  creature. 

29 


442  GROWTH    OF    CARTILAGINOUS    TUMORS. 

facts  to  make  it  probable  that  they  are  so  :  and  every  presumption  is  in 
favor  of  their  being  innocent. 

As  to  the  meaning  of  these  changes  of  the  nucleus  ;  they  may  be,  as 
Mr.  Quekett*  has  shown,  preparatory  to  ossification,  and  the  metamor- 
phosis of  the  cartilage-nucleus  into  a  bone-corpuscle  or  lacuna ;  but  in 
many  instances  they  are  unconnected  with  ossification :  for,  in  most  of 
the  cases  in  which  I  have  found  them,  the  tumor  was  in  no  part  ossified, 
and  in  many  of  them  it  was  not  of  a  kind  in  which  ossification  was 
likely  to  ensue.  In  these  cases  we  may  believe  the  change  of  the  nuclei 
to  be  connected  with  a  process  of  degeneration.  There  are  many 
grounds  for  this;  such  as  the  fact,  already  mentioned,  of  their  likeness 
to  the  nuolei  of  lower  cartilages  ;  their  likeness  in  shape  to  ramified 
pigment-cells  and  bone-corpuscles  ;  the  frequent  coincidence  of  more  or 
less  fatty  degeneration  in  the  nuclei  thus  changing;  the  usual  coinci- 
dence of  the  fusion  of  the  cell-wall  and  contents  with  the  basis-substance 
of  the  cartilage,  and  the  loosening  of  the  nuclei ;  and  the  gradual 
shrivelling  or  wasting  of  the  nuclei  after  the  assumption  of  the  stellate 
form.f 

Such  is  the  anatomy  of  cartilaginous  tumors ;  and  now,  in  relation 
to  their  physiology,  several  points  may  deserve  notice. 

Their  rate  of  growth  is  singularly  uncertain.  They  may  increase 
very  slowly.  I  have  seen  one  not  more  than  half  an  inch  long  which 
had  been  at  least  four  years  in  progress.  Or,  after  a  certain  period  of 
increase,  they  may  become  stationary  ;  as  often  happens  in  the  tumors 
that  occur  in  large  numbers  on  the  hands.  Or,  from  beginning  to  end, 
their  growth  may  be  very  rapid.  I  remember  a  man  26  years  old,  in 
St.  Bartholomew's  Hospital,  in  whom,  within  three  months  of  his  first 
noticing  it,  a  cartilaginous  tumor  increased  to  such  an  extent  that  it 
appeared  to  occupy  nearly  the  whole  length  of  his  thigh,  and  was  as 
large  round  as  my  chest.  He  had  a  pale  unhealthy  aspect,  and  suffered 
much  from  the  growth ;  and  its  size  and  rapid  growth,  the  tension  nearly 
to  ulceration  of  the  skin  over  it,  the  enlarged  veins,  and  loss  of  health, 
made  all  suppose  it  was  a  great  cancerous  tumor.  Mr.  Vincent,  there- 
fore, decided  against  amputation  of  the  limb,  and  the  patient  died  ex- 
hausted, within  six  months  of  the  first  appearance  of  the  disease.  The 
examination  after  death  proved  that  a  great  cartilaginous  tumor,  with 
no  appearance  of  cancerous  disease,  had  grown  within  and  around  the 
middle  two-thirds  of  the  femur.  The  bone,  after  extension  by  the 
growth  within  it,  had  been  broken,  and  all  the  central  part  of  the  tu- 
mor was  soft,  nearly  liquid,  and  mixed  with  fluid  blood  and  decolorized 
blood-clots. 

In  another  case,  under  Mr.  Lloyd's  care,  a  cartilaginous  tumor,  sur- 

*  Lectures  on  Histology,  p.  166. 

f  C.  O.  Weber  (Virchow's  Archiv,  vol.  vi,  1854),  states  that  he  has  seen  in  enchondromata 
lime  salts,  collected  in  such  quantities  as  to  form  large  concretions.  In  one  case  he  noticed 
they  had  a  rhombic  form,  and  thinks  they  may  probably  have  been  phosphate  of  lime. 


GROWTH,    ETC.,    IN    CARTILAGINOUS    TUMORS.  443 

rounding  the  upper  two-thirds  of  a  girl's  tibia,  grew  to  a  circumference 
of  two  feet  in  about  18  months.  Gluge*  also  mentions  a  case  in  which, 
in  a  boy  14  years  old,  a  cartilaginous  tumor  on  a  tibia  grew  in  S^  months 
to  the  size  of  a  child's  head,  and  protruded,  and  caused  such  pain  and 
hectic,  that  amputation  was  necessary. 

I  need  only  refer  to  the  importance  of  these  cases  in  their  bearing 
on  the  diagnosis  of  tumors,  and  as  exceptions  to  the  general  rule,  that 
the  malignant  grow  more  rapidly  than  the  innocent. 

In  extent  of  growth,  the  cartilaginous  tumors  scarcely  fall  short  of  the 
fibrous.  Mr.  Frogleyf  has  related  two  cases  of  tumors  of  enormous  size. 
In  one,  the  patient  was  a  young  woman  28  years  old,  and  the  tumor, 
of  nearly  five  years'  growth  around  the  shaft  of  the  femur,  extended 
from  the  knee-joint  to  within  an  inch  of  the  trochanters,  and  measured 
nearly  three  feet  in  circumference.  It  was  a  pure  cartilaginous  tumor, 
but  its  whole  central  part  was  soft  or  liquid,  and  many  of  the  nodules 
of  which  it  was  composed  had  the  character  of  cysts,  through  such  cen- 
tral softness  as  I  shall  presently  have  to  describe.  The  limb  was  re- 
moved near  the  hip-joint,  and  the  patient  has  remained  in  good  health 
for  seventeen  years  since. J 

In  the  other  case  by  Mr.  Frogley,  the  patient  was  a  lady  37  years 
old,  and  the  tumor  had  been  growing  eleven  years ;  it  was  20|^  inches 
in  circumference,  and  exactly  resembled  that  in  the  former  case.  The 
amputation  of  the  limb  was  equally  successful. 

The  tumor  in  Mr,  Lloyd's  case,  to  which  I  have  just  referred,  mea- 
sured 24  inches  in  circumference.  But  all  these  are  surpassed  by  an 
instance  related  by  Sir  Philip  Crampton,  in  which  a  tumor  of  this  kind 
surrounding  the  femur,  and  soft  in  all  its  central  parts,  measured  no 
less  than  6J  feet  in  its  circumference. 

The  only  change  of  cartilaginous  tumors  which  can  be  spoken  of  as 
a  development,  is  their  ossification  :  and  this  is,  I  believe,  in  all  essential 
and  minute  characters,  an  imitation  of  the  ossification  of  the  natural 
cartilages. 

But  the  more  general  or  larger  method  of  ossification  must  also  be 
observed.  Ossification  may  ensue,  I  suppose,  in  any  cartilaginous  tu- 
mor ;  but  it  is  rare  or  imperfect  in  those  that  grow  within  bones,  and 
is  yet  more  imperfect,  and  is  like  the  deposit  of  amorphous  calcareous 
matter,  in  those  that  lie  over  the  parotid  gland.  It  is  best  seen  in  those 
that  lie  upon  or  surround  the  bones  ;  and  in  these,  two  methods  of  ossi- 
fication may  be  noticed. 

In  one  method,  the  ossification  begins  at  the  surface  of  the  bone, 

*    Patholigische  Anatomie,  Lief.  iv. 

f  MedicoChirurgical  Transactions,  vol.  xxvi. 

X  I  have  to  thank  Mr.  Frogley  for  affording  me  this  information,  and  Mr.  Lane  for  an 
opportunity  of  exhibiting  at  the  Lecture  the  remarkable  specimen  obtained  by  the  operation, 
and  now  preserved  in  his  Museum. 


444 


GROWTH  AND  OTHER  CHANGES 


Fi^.  66  * 


where  the  cartilaginous  tumor  rests  on  it,  and  thence  the  new-formed 
bone  grows  into  the  cartilage.  Thus,  the  ossification  may  make  pro- 
gress far  into  the  substance  of  the  cartilage ;  and  the  tumor  may  ap- 
pear like  an  outgrowth  of  bone  covered  with  a  layer  or  outer  crust  of 
cartilage,  on  which  the  periosteum  is  applied.  Or,  extending  yet  farther, 
the  cartilage  may  by  this  method  be  wholly  ossified,  and  the  cartilagin- 
ous may  be  transformed  into  an  osseous  tumor. 

In  the  other  method  of  ossification,  the  new  bone  is  formed  in  the 
mid-substance  of  the  cartilage.  In  a  large  tumor  the  process  may  com- 
mence at  many  points,  and,  extending  from  each,  the  several  portions 
of  new  bone  may  coalesce  with  one  another,  and  with  that  formed  in  the 
first  method,  like  an  outgrowth  from  the  surface  of  the  original  bone. 
Indeed,  this  twofold  method  of  ossification  is  commonly  seen  in  the  large 
tumors  that  surround  long  bones. 

The  ossification  ensuing  in  several  points,  and  thence  extending,  is 
plainly,  in  these  tumors,  an  imitation  of  the  natural  ossification  of  the 

skeleton  from  centres  in 
each  of  its  constituent 
parts.  Sometimes,  in- 
deed, this  natural  pro- 
cess is  imitated  with  sin- 
gular exactness.  Thus, 
in  the  College  Museum, 
ISTo.  207,  is  a  portion  of  a 
large  tumor  which  was 
taken  from  the  front  of 
the  lumbar  vertebrae  of 
a  soldier.  Half  of  it  is 
cartilaginous,  and  half  is 
medullary  cancer.  The 
cartilaginous  portion 
consists  of  numerous 
small  nodules,  of  various 
shapes,  each  of  which  is  invested  with  a  layer  of  connective  tissue,  as 
its  perichondrium.  In  many  of  these,  a  single  small  portion  of  yellow 
cancellous  bone  appears  in  the  very  centre,  each  nodule  ossifying  from 
a  single  nucleus  or  centre,  as  orderly  as  each  cartilage  of  the  foetal 
skeleton  might  ossify. 

I  shall  speak  in  the  next  lecture  of  osseous  tumors,  and,  among 
them,  of  those  that  are  formed  by  these  methods.  It  may  therefore 
suffice  for  the  present  to  say  that,  in  nearly  all  cases,  the  bone  formed 
in  cartilaginous  tumors  consists  of  cancellous  tissue,  with  marrow  or 
medullary  substance  in  its  interspaces ;  and  that  when  the  ossification 
of  the  tumor  is  complete,  the  new  cancellous  tissue  is  usually  invested 


*  Fig.  66.  Section  of  the  cartilaginous  and  cancerous  tumor  described  in  the  text:  reduced 
one-half. 


IN    CARTILAGINOUS     TUMORS.  445 

with  a  thin  compact  layer  or  outer  wall  of  bone,  which,  if  the  tumor 
have  grown  on  a  bone,  becomes  continuous  with  the  compact  tissue  of 
that  bone. 

The  principal  defect  or  degeneration  noticeable  in  cartilaginous  tu- 
mors is  manifested  in  their  being  extremely  soft,  or  even  liquid ;  a  clear, 
yellow,  or  light  pink,  jelly-like,  or  synovia-like  material  appearing  in  the 
place  of  cartilage.  I  call  it  a  defect  or  a  degeneration,  because  it  is  not 
always  certain  whether  it  is  the  result  of  cartilage,  once  well  formed, 
having  become  soft  or  liquid,  or  whether  the  soft  or  liquid  material  be 
a  blastema,  which  has  failed  of  gaining  the  firmness  and  full  organiza- 
tion of  cartilage.  It  is  quite  probable  that  the  same  defective  structure 
would  be  found  in  arrests  of  development  as  in  degeneration  ;  and  the 
history  of  the  cases  agrees  herewith.  The  conditions  in  which  extreme 
softness  is  sometimes  found  can  leave  little  doubt,  I  think,  that  it  is  in 
these  cases  a  degeneration, — a  liquefaction  of  that  which  was  once  more 
perfectly  nourished;  but,  in  other  cases,  the  softness  of  structure  ap- 
pears to  have  characterized  the  growths  from  their  earliest  formation ; 
such,  probably,  was  the  case  of  which  the  history  is  told  on  the  next 
succeeding  page ;  but  in  many  cases  we  have  no  guide  to  the  interpre- 
tation of  the  peculiarity. 

The  soft  material  of  cartilaginous  tumors  is  like  melting,  transparent, 
yellowish,  or  pale  pinkish  jelly;  or  like  a  gum-like  substance,  or  like 
honey,  or  synovia,  or  serum.  Such  a  material  may  occupy  the  whole 
interior  of  a  cartilaginous  tumor,  one  great  cavity,  filled  with  it,  being 
found  within  a  wall  of  solid  substance.*  Or  the  whole  mass  of  tumor, f 
or  its  exposed  surface,!  maybe  thus  soft  or  liquid.  Often,  too,  we  may 
trace  in  individual  nodules  of  a  cartilaginous  tumor,  a  process  of  what 
I  suppose  to  be  central  softening,  by  which,  perhaps,  the  formation  of 
the  great  central  cavities  of  the  large  tumors  is  best  illustrated.  Thus, 
in  the  tumor  of  cartilage  and  medullary  cancer,  of  which  I  have  already 
spoken,  as  illustrating  the  process  of  ossification  from  a  centre  in  each 
nodule,  there  are  many  nodules,  in  the  centre  of  which,  instead  of  bone, 
small  cavities  full  of  fluid  are  seen.  So,  too,  in  a  large  cartilaginous 
tumor,  growing  on  the  pelvic  bones  of  a  man  forty  years  old,  a  portion 
of  which  was  sent  to  me  by  Mr.  Donald  Dalrymple,  I  found  a  large 
number  of  distinct  nodules,  each  with  a  central  cavity  full  of  honey-like 
fluid ;  and  the  state  of  the  cartilage  around  these  cavities,  its  softness, 
the  fusion  of  its  cell-walls,  and  their  contents,  with  its  hyaline  basis, 
and  the  sparing  distribution  of  nuclei  in  it,  make  me  believe  that  the 
softness  and  liquefaction  were  the  results  of  a  degenerative  process. 

*  As  in  Mr.  Progley's  case ;  and  as  in  many  nodules  of  the  tumors,  No.  207  and  others, 
in  the  Museum  of  the  College  of  Surgeons. 

j-  See  a  drawing  of  one  in  the  hand,  and  a  specimen  in  Ser.  1 115,  in  the  Museum  of  St. 
Bartholomew's,  and  the  specimen  given  to  the  Museum  by  Mr.  Bickersteth,  and  described 
on  the  next  page. 

X  Mus.  Coll.  Surg.,  No.  206. 


446  GROWTH    AND     OTHER     CHANGES 

When  the  softening  may  be  safely  regarded  as  degenerative,  it  is 
still,  often,  very  difficult  to  say  to  what  the  change  is  due.  In  some 
cases  it  appears  connected  with  the  great  bulk  of  the  tumor,  and  the 
hindrance  to  the  sufficient  penetration  of  blood  to  its  central  parts. 
Hence  it  is,  I  think,  proportionally  more  frequent  in  the  large  than  in 
the  smaller  tumors.  In  some  cases  it  may  be  due  to  exposure  of  the 
tumor,  as  in  the  instance  of  a  cartilaginous  tumor  which  grew  from  the 
sacro-iliac  symphysis  and  adjacent  bones,  and  projected  into  the  vagina 
of  a  woman  thirty-four  years  old.*  But  in  many  more  cases  we  are 
unable  to  assign  a  reason  for  such  softness. 

The  central  softening  of  single  nodules  of  cartilaginous  tumors  may 
extend  to  the  formation  of  cysts;  for  when  the  whole  of  a  nodule  is 
liquefied,  its  investment  of  connective  tissue  may  remain  like  a  cyst 
inclosing  the  liquid.  This  change  was  shown  in  the  same  tumor  as 
illustrated  the  central  ossification  and  the  central  softening.  And  it 
was  not  difficult  to  trace  in  it  what  appeared  like  gradations  from  cen- 
tral to  complete  liquefaction,  and  from  a  group  of  cartilaginous  nodules 
to  a  group  of  cysts  with  tenacious  fluid  contents. 

When  extensively  softened  or  liquefied,  or  when  almost  wholly  trans- 
formed into  cysts  with  viscid  contents,  the  cartilaginous  tumors  are 
very  like  masses  of  colloid  cancer  ;t  so  like,  that  the  diagnosis,  without 
the  microscope,  might  be  nearly  impossible.  Such  a  tumor  was  sent  to 
me  by  Mr.  E.  Bickersteth.  A  woman,  forty-five  years  old,  had  two 
tumors,  one  on  the  eminence  of  the  right  frontal  bone,  the  other  half 
an  inch  below  the  right  clavicle.  The  former  was  globular,  as  large  as 
a  walnut,  and  fixed  to  the  bone.  It  felt  soft  and  doughy,  but  at  its 
base  and  around  its  margins  it  was  hard.  The  latter  was  about  twice 
as  large,  subcutaneous,  and  freely  movable  ;  it  felt  like  a  fatty  tumor, 
except  in  that  it  was  not  distinctly  lobed,  and  was  less  firm  and  con- 
sistent than  such  tumors  usually  are.  Both  tumors  had  been  gradu- 
ally increasing  for  eight  years,  and  had  been  painless.  The  patient's 
mother  had  died  with  hard  cancer  of  the  breast. 

The  tumor  below  the  clavicle  was  removed.  It  was  an  oval  mass, 
invested  by  a  thin  connective-tissue  capsule,  partitions  from  which 
intersected  it,  and  divided  it  into  lobes  of  unequal  size,  distinct,  but 
closely  packed.  They  all  consisted  of  a  soft,  flickering,  yellow,  and 
pale  ruddy  substance,  widely  intersected  with  opaque-white  lines.  The 
substance  was  extremely  viscid,  and  could  be  drawn  out  in  strings,  stick- 
ing to  one's  fingers,  like  tenacious  gum.  Its  general  aspect  was  very 
like  that  of  a  colloid  cancer,  but  it  had  no  alveolar  or  cystic  structure, 
and  it  was  an  isolated  mass,  not  an  infiltration.  Portions  lightly  pressed 
(for  it  needed  no  dissection  for  the  microscope),  showed  as  in  the  an- 

*  Mus.  Coll.  Surg,  No.  206. 

f  I  believe  they  have  been  often  described  as  such.  I  think,  too,  that  some  of  them  are 
included  by  Vogel  in  his  group  of  "  gelatine  tumors  "  (Gallertgeschwulste),  of  which  he 
says  gelatiniform  cancers  are  the  most  frequent  form. 


IN    CARTILAGINOUS    TUMORS. 


447 


nexed  figure  (67),  together  with  a  small  quantity  of  loose  connective 
tissue  and  fat,  a  peculiar  filamentous  tissue  in  curving  and  interlacing 


Fis.  67. 


bundles,  and  in  separate  very  long  and  very  tortuous,  or  curled  fila- 
ments, or  narrow  flat  bands  (a).  The  latter  appeared  as  peculiar  pale 
filaments,  about  13^00*^  of  ^^  i^ch  in  diameter ;  in  shape  and  mode  of 
coiling  resembling  elastic  fibres,  but  not  having  dark  edges,  and  extend- 
ing to  an  extreme  length.  Such  fibres  lay  imbedded  in  a  pellucid  viscid 
substance,  and  more  abundantly  scattered  in  the  same  were  various 
corpuscles  (b).  Of  these  some  were  simple,  others  of  more  complex 
forms.  The  former  were,  generally,  nearly  round,  dimly  nebulous, 
with  one  or  two  shining  particles,  but  (unless  in  a  very  few  instances) 
without  nuclei.  These  seemed  to  be  free  nuclei,  of  which  many  had 
grown  to  an  unusual  size,  and  measured  jo^ooth  of  an  inch  in  diameter. 
The  more  complex  had  the  same  texture  as  these,  and  seemed  to  be 
also  altered  nuclei,  and  resembled  most  nearly  the  stellate  nuclei  of 
more  ordinary  cartilaginous  tumors.  They  generally  had  an  oval,  or 
round,  or  angular  body  or  central  part,  from  which  slender  processes 
passed  out.  These  followed  various  directions.  Some  were  short;  some 
branched  once  or  more;  some  were  extremely  long,  and  appeared  to 
connect  adjacent  corpuscles,  or  to  be  continued  into  some  of  the  tortu- 
ous bands  or  filaments,  like  which,  as  they  extended  farther,  they  be- 
came pale,  clear,  and  finely  edged.  The  chief  and  extreme  forms  are 
sketched,  and  many  intermediate  between  these  existed. 

Since  the  operation  the  patient  has  remained  well,  and  the  tumor  on 
the  head  has  been  stationary  for  four  months ;  so  that,  thus  far,  the 
history  has  confirmed  the  only  opinion  I  could  form  of  so  strange  a 
tumor,  namely,  that  it  was  composed  of  immature  soft  fibrous  cartilage, 
not  only  arrested,  but  in  a  measure  perverted  in  its  development.* 

*  In  a  letter  dated  December  12th,  1862,  Mr.  Bickersteth  states  that  he  has  not  seen  or 
heard  anything  of  this  patient  since  her  discharge  from  the  hospital. 


448  CARTILAGINOUS    TUMORS     OF    THE    BONES. 

The  softened  central  parts  of  cartilaginous  masses  are  apt  to  be 
affected  with  rapid  sloughing  or  suppuration.  Such  an  event  occurred 
in  Sir  Philip  Crampton's  case,  already  quoted,  and  in  one,  presenting 
many  features  of  great  interest,  which  was  under  Mr.  Lloyd's  care,  at 
St.  Bartholomew's  Hospital.*  A  girl,  14  years  old,  was  admitted  with 
a  very  large  tumor  round  the  upper  two-thirds  of  the  tibia.  It  had 
been  growing  for  18  months,  and  shortly  before  her  admission,  without 
evident  cause  (unless  it  were  that  it  had  been  punctured),  the  integu- 
ments over  it  began  to  look  inflamed  and  dusky.  The  limb  was  ampu- 
tated almost  immediately  after  her  admission ;  and  the  tumor  presented 
in  its  anterior  a  large  cavity  with  uneven  broken  walls,  filled  with 
brownish  serous  fluid  of  horribly  offensive  putrid  odor.  The  inner  sur- 
face of  the  walls  of  the  cavity  appeared  also  putrid,  and  gases,  the 
products  of  the  decomposition,  were  diffused  in  the  areolar  tissue  as  far 
as  the  middle  of  the  thigh. 

Other  changes  of  a  degenerative  character  may  be  sometimes  ob- 
served in  cartilaginous  tumors.  "  Parts  of  them  may  appear  grumous  or 
pulpy,  and  of  an  ochre  yellow  color. f  This  is  probably  a  fatty  degene- 
ration of  their  tissue.  And,  sometimes,  as  I  ha.ve  said,  their  ossification 
is  so  imperfect  as  to  be  more  like  a  fatty  and  calcareous  degeneration, 
in  which  their  substance  becomes  like  fresh  mortar,  or  soft  chalk,  and, 
when  dry,  is  powdery,  and  white,  and  greasy. J 

It  may  serve  for  additional  illustration  of  this  general  pathology  of 
cartilaginous  tumors,  if  I  describe  now  some  particular  form  of  them. 

I  have  said  that  they  chiefly  affect  the  bones.  The  bones  of  the 
hands  are  their  most  frequent  seats ;  and  next  to  these,  the  adjacent 
extremities  of  the  femur  and  tibia,  the  parts  which,  for  some  inexplicable 
reason,  appear  to  have  in  all  the  skeleton  the  least  power  of  resistance 
of  disease.  After  these,  the  humerus,  the  last  phalanx  of  the  great  toe, 
the  pelvis,  and  the  ribs,  appear  most  liable  to  cartilaginous  growths  ; 
and  after  these,  the  number  of  cases  is  as  yet  too  small  to  assign  an 
order  of  frequency,  but  there  is  scarcely  a  bone  on  which  they  have 
not  been  seen. 

Of  the  cartilaginous  tumors  of  the  large  long  bones  I  need  say  little, 
having  drawn  from  them  the  greater  part  of  the  general  description. 
Only,  the  relations  of  the  growths,  according  to  the  part  of  the  bone  in 
or  near  which  they  lie,  may  be  worth  notice. 

When,  then,  the  tumor  grows  at  or  about  the  articular  end  of  a  large 
long  bone,  it  is  almost  wholly  placed  between  the  periosteum  and  the 
bone.  Here  it  usually  surrounds  the  bone,  but  not  with  a  uniform 
thickness;   and  the  thin  wall  of  the  bone  wastes  and  gradually  disap- 

*  It  is  fully  reported  in  the  Lancet,  December,  1850.  The  specimen  is  in  the  Museum 
of  the  hospital. 

t  Mus.  Coll.  Surg.,  No.  200. 

J  Mus.  Coll.  Surg.,  No.  204.  Rokitansky,  B.  i,  p.  262.  Dr.  Humphry  has  particularly 
described  this  change  in  his  Lectures,  p.  142. 


CARTILAGINOUS    TUMORS    OF    THE    BONES. 


449 


pears  as  if  it  were  eroded,  or  as  if  it  changed  its  form,  becoming  can- 
cellous, and  then  growing  into  the  tumor.  I  have  never  seen  such  a 
tumor  encroaching  on  the  articular  surface  of  a  bone  ;  but  it  maj  grow 
up  all  about  the  borders  of  the  joint,  and  surround  them.  A  striking 
example  of  these  relations  of  the  cartilaginous  tumor  to  the  bone  on 
which  it  grows  is  in  one  of  the  best  and  most  characteristic  specimens 
in  the  College  Museum;*  a  cartilaginous  tumor  of  the  humerus,  removed 
in  an  amputation  at  the  shoulder-joint  bj  Mr.  Liston.  His  sketch  of 
it  is  here  copied.  The  patient  was  a  naval  surgeon,  and  the  tumor  had 
been  growing  for  nearly  forty  years. 
The  mass  it  now  forms  is  nearly 
ten  inches  across  ;  it  surrounds  the 
upper  three-fourths  of  the  shaft  of 
the  humerus,  and  nearly  surmounts 
its  articular  surface ;  and  it  shows 
abundant  isolated  nodules,  partial 
central  ossification  and  central  soft- 
ening, and  the  growth  of  bone  from 
the  cancellous  tissue  of  the  humerus 
into  the  tumor.  It  shows,  too,  very 
well,  how  bloodvessels  and  nerves 
are  imbedded  in  the  inequalities  of 
such  tumors,  without  being  involved 
by  them. 

It  is  extremely  rare,  I  think,  for 
a  cartilaginous  tumor  to  grow  with- 
in the  articular  end,  or  in  the 
medullary  tissue  near  it,  in  a  large 
long  bone.  A  striking  specimen, 
hoAvever,  was-  presented  by  Mr. 
Langston  Parker  to  Mr.  Stanley. 
It  was  removed,  by  amputation  of 
the  lower  part  of  the  leg,  from  a 

young  gentleman  in  whom  it  had  grown  slowly,  and  had  distinctly  pul- 
sated. The  lower  end  of  the  fibula  is  expanded  and  wasted  by  a  growth 
of  cartilage,  mixed  with  a  substance  such  as  will  be  described  in  the 
next  lecture,  as  the  characteristic  material  of  the  fibro-plastic  or  mye- 
loid tumors.  The  growth  is  rather  larger  than  an  egg,  and  is  invested 
by  the  remains  of  the  expanded  fibula,  and  by  the  periosteum  ;  and 
the  relations  of  the  chief  bloodvessels  make  it  probable  that  the  pul- 
sation felt  during  life  was  derived  from  that  of  the  vessels  within  the 
tumor.f 


*  Mus.  Coll.  Surg.,  No.  779.  The  patient  recovered  from  the  operation,  but  died  two 
months  afterwards  with  disease  of  the  chest.  The  specimen  is  represented  in  Mr.  Liston's 
Practical  Surgery,  p.  374,  from  which  the  sketch  (Fig.  68)  is  drawn. 

■f  The  specimen  is  in  the  Museum  of  St.  Bartholomew's  Hospital.     No.  783  in  the  Mus. 


450  CARTILAGINOUS    TUMORS    OF    THE    BONES. 

When  a  cartilaginous  tumor  grows  at  the  middle  of  the  shaft  of  a 
large  long  bone,  it  is,  I  think,  usual  to  find  coincidently  both  an  exter- 
nal and  an  internal  growth.  Cartilage  lies  outside  the  shaft,  beneath 
the  periosteum ;  and  another  mass  may  fill  the  corresponding  portion 
of  the  medullary  canal.  Then,  in  the  concurrent  growth  of  the  two 
masses,  the  wall  of  the  bone  between  them  wastes  or  is  broken  up,  and 
they  may  form  one  great  tumor  set  between  the  portions  of  the  shaft.* 
These  are  the  cartilaginous  tumors  which  most  imitate  the  progress  of 
malignant  disease.  They  are  indeed  very  rare ;  but  the  chance  of  the 
existence  of  such  a  one,  where  we  might  be  anticipating  a  malignant 
tumor,  is  always  to  be  added  to  the  motives  for  amputation  in  cases  of 
tumors  round  the  shafts  of  these  long  bones. 

Such  are  some  of  the  chief  facts  to  be  noted  about  the  cartilaginous 
tumors  on  the  large  long  bones. 

On  the  jaws  these  tumors  are,  I  believe,  very  rare.  I  know  but  one 
specimen  on  the  upper  jaw  alone  ;  a  great  tumor,  portions  of  which  are 
preserved  in  the  Museum  of  Guy's  Hospital,  and  of  which  the  history, 
by  Mr.  Morgan,  is  in  the  Hospital  Reports. 

On  the  lower  jaw,  such  tumors  appear  prone  to  acquire  a  peculiar 
shape,  affecting  the  whole  extent  of  the  bone.  One  of  the  most  re- 
markable tumors  in  the  Museum  of  the  Collegef  is  of  this  kind.  The 
patient  was  a  lady  39  years  old.  The  tumor  had  been  growing  eight 
years ;  it  commenced  as  a  small  hard  tumor  just  below  the  first  right 
molar  tooth,  and  gradually  enlarged  till  it  inclosed  the  whole  jaw,  ex- 
cept its  right  ascending  portion.  It  measured  two  feet  in  circumference, 
and  six  inches  in  depth,  and  the  patient  died  exhausted  by  want  of 
food,  which  she  was  unable  to  swallow,  and  by  the  ulceration  of  parts  of 
the  tumor  during  the  last  two  years  of  her  life. 

M.  Lebert|  has  recorded  a  case  in  which  a  tumor  like  this  was  re- 
moved by  Dieffenbach.  In  three  successive  operations  he  removed  it 
by  instalments,  and  the  patient  finally  recovered. 

The  cartilaginous  tumors  that  grow  about  the  cranial  bones  and  the 
vertebrae  show,  in  a  marked  manner,  that  reckless  mode  of  growth  (if  I 
may  so  speak)  which  is  more  generally  a  characteristic  of  malignant 
tumors.     They  grow  in  every  direction ;  pressing,  and  displacing,  and 

Coll.  Surg.,  is  an  ossified  cartilaginous  tumor  within  the  upper  end  of  the  fibula.  In  the 
Museum  of  St.  Thomas's  Hospital  is  a  most  remarkable  instance  of  cartilaginous  tumors 
growing,  at  once,  in  the  scapula,  the  upper  part  of  the  humerus,  and  the  lower  part  of  the 
same.  In  the  last-named  part  the  cartilage  lies  within  the  thinned  walls  of  the  bone.  The 
case  is  described  by  Mr.  William  Adams,  in  the  Proc.  of  the  Pathol.  Soc,  vol.  ii. 

*  A  specimen  of  this  form  is  in  the  Museum  of  St.  Bartholomew's  in  and  upon  a  femur, 
in  Ser.  i,  No.  Ill  ;  and  one  of  very  large  size,  around  and  in  the  upper  third  of  the  femur, 
is  in  Guy's  Hospital  Museum.  One  also  is  mentioned  by  Mr.  Hawkins  as  occurring  in  the 
middle  of  the  shaft  of  the  humerus  (Medical  Gazette,  vol.  xxv,  p.  476).  Mr.  Syme  also  re- 
cords two  cases  in  the  Ed.  Med.  Jal.,  Jan.,  1854,  p.  4.  The  tumors  in  both  cases  occurred 
in  the  humerus,  in  which  bone,  next  to  the  maxillary  bones,  he  thinks  this  form  of  tumor 
most  frequently  appears. 

t  Nos.  1034  and  201.  J  Abhandlungen,  p.  197. 


CARTILAGINOUS    TUMORS     ON     THE    HANDS.  451 

leading  to  the  destruction  of,  important  parts,  and  tracking  their  way 
along  even  narrow  channels. 

In  St.  Bartholomew's  is  a  tumor,*  composed,  for  the  most  part,  of 
cartilage,  which  grew  in  connection  with  the  bones  of  the  face  and  head 
of  a  lad  16  years  old.  It  involved  both  superior  maxillary  bones,  ex- 
tended into  the  left  orbit,  and  through  the  left  side  of  the  base  of  the 
skull  into  its  cavity,  compressing  the  anterior  lobes  of  the  cerebrum : 
it  was  also  united  to  the  soft  palate,  and  protruded  the  left  nostril,  and 
the  integuments  of  the  face. 

The  commencement  of  a  similar  growth  is  probably  shown  in  a  spe- 
cimen in  the  College  Museum, f  in  which,  together  with  changes  effected 
by  the  growth  of  nasal  polypi,  one  sees  the  ethmoid  cells  completely 
filled  with  firm  semi-transparent  cartilage,  a  mass  of  which  projects  in 
a  round  tumor  into  the  upper  part  of  the  left  nasal  fossa. 

And  here  I  may  adduce,  in  proof  of  the  tracking  growth  of  the  car- 
tilaginous tumors,  the  case  of  one|  originating  in  the  heads  of  the  ribs, 
which  extended  through  the  intervertebral  foramina  into  the  spinal 
canal,  where,  growing  widely,  and  compressing  the  spinal  cord,  it  pro- 
duced complete  paralysis  of  the  pelvic  organs  and  the  lower  extre- 
mities. 

The  cartilaginous  tumors  of  the  hands  deserve  a  special  notice. 

As  many,  I  believe,  as  forty  cases  might  be  collected  from  various 
records,  in  which  the  bones  of  one  or  both  hands,  and  sometimes  of  the 
feet  also,  have  been  the  seats  of  numerous  cartilaginous  tumors.  Seve- 
ral of  these  cases  were  collected  by  John  Bell  ;§  many  more  by  Muller,|| 
who  drew,  indeed,  from  these  cases  the  greater  part  of  his  general  ac- 
count of  enchondroma ;  and  many  more  might  now  be  added  to  the  list. 
Four  admirable  specimens  of  the  disease  are  in  the  Museums  of  the 
College  and  of  St.  Bartholomew's. 

The  first  of  these,T[  from  the  collection  of  Sir  Astley  Cooper,  consists 
of  the  amputated  fingers  and  heads  of  the  metacarpal  bones  of  a  girl  13f 
years  old.  Tumors  had  been  growing  in  these  bones  for  eleven  years  ; 
and  now  there  are  eleven  or  twelve,  from  half  an  inch  to  an  inch  and  a 
half  in  diameter,  and  all  formed  of  pure  cartilage. 

The  second  was  presented  to  the  Museum  of  St  Bartholomew's  by 
Mr.  Hodgson.**     It  comprises  the  right  hand,  and  the  little  finger  of 

*  Mns.  St.  Bartholomew's  Hospital,  Ser.  xxxv,  No.  47.  Drawn  in  Mr.  Stanley's  Illustra- 
tions of  Diseases  of  the  Bones,  pi.  xvii,  fig.  4. 

t  Mus.  Coll.  Surg,  2199. 

J  Mus.  St.  Bartholomew's  Hospital,  Ser.  i,  No.  115. 

§  Principles  of  Surgery,  vol.  iii,  p.  65. 

II  On  Cancer.  Whenever  the  statements  made  by  Miiller  respecting  the  general  charac- 
ters of  cartilaginous  tumors  differ  from  the  account  here  given,  the  differences  may,  I  think, 
be  explained  by  his  taking  for  the  type  the  tumors  of  the  hand.  This  alone  could  have 
made  him  regard  so  little  the  ossification  of  cartilaginous  tumors. 

f  Mus.  Coll.  Surg.,  775. 

**  Described  in  the  Pathological  Appendix  to  the  Catalogue. 


452 


CARTILAGINOUS  TUMORS  ON  THE  HANDS. 


the  left  hand,  of  a  lad  14  years  old,  in  whom,  without  any  known  cause, 
the  tumors  had  been  growing  from  early  childhood.  In  the  right  hand, 
the  metacarpal  bone  of  the  thumb  contains  two  tumors  ;  and  of  the  fore 
finger  three  or  four  tumors,  of  which  the  smallest  is  an  inch,  and  the 
largest  is  three  inches  in  diameter  :  the  first  and  second  phalanges,  also, 
of  the  fore  finger,  contain  tumors ;  the  middle  finger  appears  normal ; 
the  third  finger  has  one  tumor  in  its  metacarpal  bone,  one  in  its  first 
phalanx,  and  two  in  its  second  phalanx  ;  the  little  finger  has  as  many, 
in  corresponding  positions.  On  the  left  hand  the  only  tumor  was  that 
in  the  first  phalanx  of  the  fore  finger. 

A  third  preparation*  contains  the  fore  and  little  fingers  removed  by 
Mr.  Lawrence  from  a  healthy  lad  17  years  old.  He  had  on  his  lefb 
hand  four,  and  on  his  right  hand  six  tumors ;  but  those  that  were  re- 
moved were  alone  troublesome  and  increasing.  They  varied  from  one 
inch  and  a  half  to  one-third  of  an  inch  in  diameter,  were  all  covered 
with  healthy  smooth  skin,  and  appeared  to  grow  from  the  interior  of 
the  bones.  No  account  could  be  given  of  their  origin,  except  that  they 
began  to  grow  when  he  was  five  years  old  ;  and  some  grew  more  quickly 
than  others.  In  both  fingers  a  formation  of  cartilage  had  occurred  in 
the  metacarpal  bones  and  the  second  phalanges,  which  was  attended 
with  scarcely  any  swelling  :  indeed,  till  the  operation  was  being  per- 
formed, these  bones  were  not  supposed  to  be  the  seats  of  disease,  though 
their  medullary  cavities  were  quite  full  of  cartilage. 

The  fourth  specimen, 
here  sketched,  is,  I  believe, 
the  most  remarkable  yet 
seen.  I  received  it  from 
Mr.  Salmon,  of  Wedmore. 
It  is  the  right  hand  of  a 
laborer,  56  years  old,  from 
whom,  when  he  was  16 
years  old,  the  fore  finger 
of  the  left  hand  was  re- 
moved with  a  tumor  weigh- 
ing 2  lb.  5  oz.  The  little 
finger  of  the  same  hand  has 
a  tumor  about  as  large  as  a 
walnut :  the  whole  length  of 
his  left  tibia  has  irregular 
nodules  on  its  anterior  and 
inner  surface,  and  some 
enlargement  exists  at  his 
left  second  toe.  On  the 
right  hand,  which  Mr.  Sal- 

*  Mus.  St.  Bartholomew's,  Pathol.  Appendix. 

f  Fig.  69.     Hand  with  cartilaginous  tumors,  described  above.     Reduced  to  one-fifth  of 
the  natural  size. 


Fig.  69. t 


CARTILAGINOUS     TUMORS    ON    THE     HANDS.  453 

men  amputated,  there  are  tumors  on  every  finger,  and  one  spheroidal 
mass  nearly  six  inches  in  diameter,  in  which  the  second  and  third  fingers 
appear  completely  buried,  the  walls  of  their  phalanges  being  only  just 
discernible  at  the  borders  of  the  mass  that  has  formed  by  the  coalition 
of  tumors  that  grew  within  them. 

The  disease  which  these  specimens  illustrate  begins,  I  believe,  ex- 
clusively in  the  early  period  of  life  ;  during  childhood,  or  at  least 
before  puberty,  and  sometimes  even  before  birth.  It  occurs,  also, 
much  more  frequently  in  boys  than  in  girls.  One  or  more,  or  nearly 
all,  of  the  phalanges  or  metacarpal  bones  of  one  or  both  hands  may  en- 
large slowly,  and  without  pain,  into  an  oval,  or  round  or  heart-shaped 
swelling.  When  such  swellings  are  grouped,  they  produce  strange 
distortions  of  the  hands,  making  them  look  like  those  of  people  who 
have  accumulated  gouty  deposits  ;  or,  as  John  Bell  delights  to  repeat, 
like  the  toes  and  claws  of  sculptured  griffins.  They  may  greatly  elon- 
gate the  fingers,  but  they  more  commonly  press  them  asunder,  limiting 
and  hindering  their  movements. 

There  is  no  rule  or  symmetry  observed  in  the  affections  of  the  hands, 
except  that  the  thumb  is  less  frequently  than  the  fingers  the  seat  of 
growths. 

In  the  large  majority  of  cases,  if  not  in  all,  each  tumor  grows  within 
a  bone,  the  walls  of  which  are  gradually  extended  and  adapted  to  its 
growth.  And  this  position  within  the  bones  is  the  more  remarkable, 
because,  in  the  cases  of  single  cartilaginous  tumors  of  the  fingers  or 
hands,  the  growth  takes  place  not  more,  but  rather  Igss,  often  within 
than  without  the  bone  ;  these  single  tumors  commonly  growing,  as  those 
of  the  larger  long  bones  do,  between  the  periosteum  and  shaft.* 

Thus,  growing  within  the  bones,  the  cartilaginous  tumors  may  be 
sometimes  found,  even  in  the  same  hand,  in  all  stages  of  growth.  One 
phalanx  or  metacarpal  bone  may  have  its  medullary  cavity  full  of  car- 
tilage without  any  external  appearance  of  enlargement ;  another  may  be 
slightly  swollen  out  at  one  part,  or  in  its  whole  periphery  ;  another  so 
extended  on  one  side,  or  uniformly,  that  its  walls  form  only  a  thin  shell 
around  the  mass  of  cartilage  ;  in  another  the  cartilage  may  have  grown 
out  through  holes  absorbed  in  the  walls  of  the  bone,  and  may  then 
have  spread  out  on  its  exterior  ;  while  from  another  it  may  have  pro- 
truded through  apertures  even  in  the  integuments,  gradually  thinned 
and  ulcerated  :f  or,  as  the  specimen  sketched  in  Fig.  69  shows,  we  may 
find  not  only  such  a  protrusion  through  integuments,  but  two  originally 
distinct  tumors,  growing  out  beyond  the  limits  of  their  respective  bones, 
and  coalescing  in  one  huge  mass.     In  cases  of  this  kind,  the  cartila- 

*  Mus.  Coll.  Surg.,  No.  772-3. 

f  A  good  case  illustrating  the  last-mentioned  fact  is  represented  by  Professor  Miller,  in 
his  Principles  of  Surgery,  p.  450,  3d  ed.  The  tumor  on  the  back  of  the  metacarpus  weighed 
fourteen  pounds,  and  after  protrusion,  bled  frequently.  John  Bell  also  has  recorded  several 
such  cases. 


454  CARTILAGINOUS   TUMORS 

ginous  mass  in  each  bone  usually  appears  as  a  single  tumor,  with  very 
delicate,  if  any,  partitions.  It  may  have  a  coarsely-granulated  aspect, 
but  it  is  rarely  divided  into  distinct  nodules,  or  strongly  intersected. 
Its  exterior  is  adapted  closely  to  the  interior  of  the  shell  of  bone,  but 
is  not  continuous  with  it,  except  by  bloodvessels.  It  rarely  ossifies,  ex- 
cept in  a  few  small  scattered  cancellous  masses  in  its  mid-substance.* 
And  it  is  worth  observing,  that  the  tumors  often  project  on  only  one 
side  of  a  bone ;  for  when  this  happens  in  the  metacarpus,  it  is  often 
very  hard  to  tell  which  of  two  adjacent  metacarpal  bones  should  be  cut 
out  in  case  of  need. 

The  cases  of  this  singular  disease  have  shown  great  diversity  as  to 
the  course  of  the  tumors,  and  in  their  modes  and  rates  of  growth  ;  some 
making  progress,  some  remaining  stationary  ;  and  I  believe  it  has  often 
happened  that  at  the  time  of  manhood  all  have  ceased  to  grow.  But 
in  regard  to  all  these  questions,  important  as  they  are,  we  are  yet  in 
need  of  facts. 

It  would  be  easy,  and  as  vain  as  easy,  to  speculate  on  the  meaning 
of  such  a  disease  as  this.  I  believe  no  reasonable  explanation  of  it 
can  as  yet  be  given,  unless  it  may  be  said  that  these  are  the  results  of 
an  exuberant  nutrition  similar  to  that  which  in  the  embryo  may  produce 
supernumerary  limbs,  but  is  here  more  disorderly  and  less  vigorous. 

The  only  remaining  instances  of  cartilaginous  tumors  to  which  I  shall 
refer  are  those  that  grow  near  the  parotid,  or,  much  more  rarely,  near 
the  submaxillary  gland. f  Some  of  these  are  formed  of  pure  cartiliage, 
and  might  be  taKen  as  types  of  the  cartilaginous  tumor  ;  but  more  are 
composed  of  cartilage,  or  fibrous  cartilage,  variously  mixed  with  other 
tissues,  and  especially  with  what  appears  to  be  an  imperfect  or  a  per- 
verted glandular  tissue.  Whichever  of  these  forms  they  may  have, 
they  are  commonly  imbedded  in  the  gland.  They  are  sometimes  wholly 
surrounded  by  the  gland-substance,  but  much  more  commonly  are  more 
or  less  deeply  imbedded  in  it,  and  covered  with  its  fascia. 

These  tumors  are  generally  invested  with  tough  capsules  of  connec- 
tive tissue,  which,  though  sometimes  loose,  are  more  commonly  so 
closely  attached  to  the  surrounding  parts  that  it  is  difiicult  to  dissect 
them  out.  And  the  inconvenience  of  this  is  not  a  little  increased  by 
the  frequent  contact  of  branches  of  the  facial  nerve,  which  are  apt  to 
adhere  very  closely  to  the  deep  part  of  the  tumor,  or  to  be  imbedded 
between  its  lobes,  or  may  even  stretch  over  its  surface. | 

*  Specimens  of  ossification  are  in  the  College  Museum,  No.  785-6. 

f  These  are  grouped  by  Rokitansky  as  the  third  variety  of  the  Gelatinous  Sarcoma,  with 
a  recognition  of  their  affinity  to  Enchondroma.  Mr.  Syme  names  them  "  Fibro-cartilaginous 
Sarcoma"  (Principles  of  Surgery,  vol.  i,  p.  89).  The  first  good  description  of  them  was 
given  by  Mr.  Lawrence  (in  his  paper  on  Tumors,  already  often  quoted).  Mr.  Csesar  Haw- 
kins described  them,  for  the  most  part,  as  "  conglomerate  tumors." 

J  The  imbedding  of  important  parts  in  a  cartilaginous  tumor  needs  to  be  remembered. 
In  the  Museum  of  St.  George's  Hospital  is  a  specimen  of  this  kind,  about  seven  inches  in 


OVER  THE  PAROTID  &LAND. 


455 


Fio;.  70.* 


The  general  aspect  of  these  tumors  depends  much  on  the  proportion 
in  which  the  cartilage  and  their  other  component  tissues  are  mixed. 
When  they  are  of  pure  cartilage,  or  when  the  cartilage,  or  delicately 
fibrous  cartilage,  greatly  predominates, 
they  may  present  all  the  general  charac- 
ters that  are  already  described.  Such 
a  case  is  illustrated  by  that  to  which, 
among  all  the  specimens  of  the  kind, 
the  primacy  belongs.  It  was  removed 
by  Mr.  Hunter,  and  is  enough  to  prove 
the  skill  and  boldness  as  an  operator 
which  some  have  denied  him.  The  case 
was  that  of  a  man,  thirty-seven  years 
old,  who,  sixteen  years  previously,  fell, 
and  bruised  his  cheek.  Shortly  after 
the  injury,  the  part  began  to  swell,  and 
the  swelling  regularly  increased  for  four 
or  five  years,  when  he  again  fell  and 
struck  the  swelling,  which,  after  this, 
extended,  especially  at  its  lower  part 
and  base.  It  seemed  quite  loose,  and 
movable  without  pain.  Mr.  Hunter  ex- 
tirpated it,  and  with  complete  success. 
It  weighed  144  ounces,  and  measures  in 
its  chief  dimensions  9  inches  by  7.  It 
presents  a  striking  instance  of  the  con- 
glomerate cartilaginous  tumor,  consisting  of  numerous  round  masses  of 
pale,  semi-transparent,  glistening  cartilage,  connected  by  their  several 
areolar  investments  ;  and  its  exterior  is  deeply  lobed  and  nodulated. 
Its  apparent  composition  is  confirmed  by  the  microscopic  examinations 
of  Mr.  Quekett,f  who  found  it  composed  of  cartilage,  in  which  some  of 
the  intercellular  substance  is  homogeneous,  and  some  finely  fibrous. 

But  when  in  these  tumors  the  cartilage  is  equalled  or  exceeded  in 
quantity  by  the  other  tissue  of  which  they  may  consist,  we  may  find 
the  same  oval  and  nodular  or  lobed  form,  and  the  same  hardness  or 
firmness  and  elasticity,  but  they  appear  on  section,  opaque  white  or 
cream-colored,  and  less  glistening  than   cartilage. J     Generally,  these 


diameter,  which  was  sent  to  the  Museum  with  the  history,  that,  in  removing  it  from  the 
deep  tissues  of  the  thigh,  tlie  femoral  artery  was  cut  across  where  passing  through  its  sub- 
stance. 

*  Fig.  70.  Minute  structures  of  a  mixed  cartilaginous  tumor  over  the  parotid  gland. 
In  the  upper  sketch,  a  group  of  withered,  stellate,  cartilage-nuclei  are  encircled  with  fibrous 
tissue.  Others  lie  near  the  group  :  while,  equally  near,  are  well-formed  cartilage-cells,  and 
groups  of  small  nuclei  or  nucleated  cells,  like  those  of  gland-structures.  In  the  lower  sketch 
similar  corpuscles  are  grouped  as  in  the  acinus  of  a  gland. 

f  Histological  Catalogue,  vol.  i,  p.  Ill,  Ag.  52. 

J  They  are  among  the  tumors  which  one  finds  described  as  like  turnips  or  like  potatoes. 


456       CARTILAGINOUS    TUMORS    OVER    THE    PAROTID    GLAND. 

mixed  tumors  appear  uniform ;  but,  sometimes,  portions  of  purer  carti- 
lage are  imbedded  in  the  mixed  tissue,  and  obscurely  bounded  from  it. 

In  microscopic  characters  the  cartilaginous  part  of  these  tumors  has, 
I  believe,  no  peculiarity  ;  different  specimens  may  offer  all  the  variety  of 
forms  to  which  I  have  already  referred. 

The  tissue  mixed  with  the  cartilaginous  is  at  present,  I  think,  of 
uncertain  nature.  In  several  cases  I  have  found  it,  for  the  most  part, 
present  a  lobed  and  clustered  structure,  Avith  fibrous-looking  tissue  en- 
circling spaces  that  are  filled  with  nuclei  and  cells.  These  inclosed 
spaces  look  so  like  the  acini  of  a  conglomerate  gland,  that  they  seem 
to  confirm  the  opinion  one  might  form  from  its  general  aspect ;  namely, 
that  it  is  an  imitation  of  gland-tissue.  And  this  is  confirmed  by  the 
character  of  the  cells  within  the  seeming  acini ;  for  they  have  the  gene- 
ral traits  of  gland-cells.  They  are  usually  small,  round  or  oval,  flat- 
tened, dimly  granular,  with  nearly  round,  pellucid  nuclei  with  nucleoli. 
They  lie  either  like  a  thin  epithelial  lining  of  the  spaces  I  just  men- 
tioned, or  else  they  are  clustered  within  them  ;  or  they  may  be  irregu- 
larly grouped  through  the  whole  substance  of  the  tumor  ;  and  in  all 
cases  abundant  free  nuclei  like  their  own  are  mingled  with  them.* 

Such  are  the  most  general  characters  of  these  cells ;  but  they  are 
apt  to  vary  from  them,  being  more  angular,  or  bearing  processes,  or 
being  attenuated  or  caudate.  Even  if  we  may  consider  them  as  imita- 
ting gland-structures,  yet  it  may  be  a  question  whether  they  are  related 
to  the  adjacent  parotid  gland,  or  to  lymphatic  gland.  It  would  be  easy 
to  discriminate  between  the  elements  of  the  parotid  and  of  a  lymphatic 
in  their  natural  state ;  but  a  morbid  imitation  of  either  of  them  may 
deviate  far  enough  to  be  as  much  like  the  other.  And  it  is  well  to  re- 
member that  these  tumors  have  exactly  the  seats  of  naturally  existing 
lymphatic  glands,  and  are  often  closely  imitated  by  mere  enlargements 
of  these  glands ;  so  that,  possibly,  future  researches  may  prove  that 
they  are  cartilaginous  tumors  growing  in  and  with  a  lymphatic  gland 
over  or  within  the  parotid  or  submaxillary  gland. 

In  general  history,  especially  in  their  slow  and  painless  growth,  the 
absence  of  any  morbid  influence,  except  that  produced  by  pressure  on 

*  Although  the  tissue  mingled  with  the  cartilaginous  may  not  unfrequently  simulate 
gland  tissue,  yet  the  star-like  and  spindle-shaped  cells,  imbedded  in  a  jelly-like  or  almost 
fluid  mass,  so  often  found  in  these  tumors  over  the  parotid,  belong,  without  doubt,  to  that 
embryonal  connective  or  mucous  tissue,  which  has  already  been  referred  to  (pp.  402,  415), 
as  occasionally  entering  into  the  structure  of  other  tumors.  This  form  of  tissue  blends  in 
various  ways,  as  Billroth  more  especially  describes,  with  the  cartilaginous,  and  together 
with  it  may  constitute  entire  tumors  over  the  salivary  glands.  Forster  thinks  that  from  what 
he  has  seen  (Atlas,  Taf  xix,  p.  1),  he  is  justified  in  stating  that  this  mucous  tissue  may  be- 
come converted  into  cartilaginous,  the  soft  mucous  basis-substance  gradually  passing,  with- 
out any  sharp  lines  of  demarcation,  into  cartilaginous  basis-substance,  in  which  the  cartilage 
cells  possess  a  spindle  or  star-like  form  with  anastomosing  processes.  Much  additional  in- 
formation respecting  the  structure  of  salivary  glandular  tumors  may  be  found  in  a  paper  by 
Billroth,  in  Virchow"s  Archiv,  vol.  xvii,  p.  357,  1859. 


RECURRENT    CARTILAGINOUS     TUMORS.  457 

the  surrounding  parts,  the  absence  of  proneness  to  foul  ulceration,  and 
of  tendency  to  return  after  removal ;  in  all  these,  the  tumors  over  the 
parotid  agree,  I  believe,  with  the  other  forms  of  cartilaginous  tumors. 
I  will  therefore  not  delay  to  relate  cases  of  them  ;  but  will  draw  towards 
conclusion  by  referring  to  some  points  connected  with  the  general  his- 
tory and  nature  of  the  whole  group  of  cartilaginous  tumors. 

First,  then,  concerning  their  origin  :  They  begin,  in  a  large  majority 
of  cases,  in  early  life  ;  between  childhood  and  puberty.  Yet  they  may 
begin  late  in  life.  I  saw  one  on  the  hand,  which  had  been  of  no  long 
duration  when  it  was  removed  from  a  man  70  years  old ;  another,  grow- 
ing in  the  humerus,  and  described  by  Mr.  W.  Adams,*  had  grown 
quickly  in  a  man  of  61 ;  another  began  to  grow  at  the  same  age,  in  a 
woman's  thumb. f  Most  commonly,  also,  those  in  or  near  the  parotid 
appear  in  or  after  middle  age. 

Then,  concerning  their  nature :  they  may  be  regarded  as,  usually, 
completely  innocent  tumors,  and  yet  there  are  some  cases  recorded,  in 
which  we  must  believe  that,  after  a  cartilaginous  tumor  has  been  re- 
moved, another  has  grown  in  the  same  place.  I  saw  one  such  in  a 
Avoman  30  years  old,  in  whom,  soon  after  the  removal  of  one  tumor 
from  the  parotid  region,  another  grew  and  acquired  a  great  size.  This 
was  an  unmixed  cartilaginous  tumor;  and  I  believe  the  first  was  of  the 
same  nature.  Dr.  Hughes  BennettJ  has  related  a  case  in  which  Mr. 
Syme  removed  a  cartilaginous  tumor  of  the  arm  by  amputation  at  the 
shoulder-joint.  Subsequently,  the  patient,  a  girl,  14  years  old,  died 
with  tumors  in  the  stump  and  axilla.  Mr.  Listen  removed  a  portion  of 
the  scapula,  with  a  great  tumor  in  its  spine  and  acromion,  which  I  have 
no  doubt  is  a  soft  and  cartilaginous  tumor. §  Three  years  afterwards 
the  patient  died,  with  what  is  described  as  a  return  of  the  disease. 
Mr.  Fergusson  showed  at  the  Pathological  Society  a  fibro-cartilaginous 
tumor||  of  the  lower  jaw,  which  had  grown  twice  after  the  complete 
removal  of  similar  tumors  from  the  same  part.  In  the  Museum  at 
Guy's  Hospital,  also,  there  is  a  cartilaginous  tumor  growing  from  the 
angle  of  the  lower  jaw  into  the  mouth,  which  is  said  to  have  grown 
after  complete  removal  of  a  similar  tumor  with  the  portion  of  lower 
jaw  to  which  it  was  connected.  Lastly,  Professor  Gluge^f  records  two 
cases,  in  which  we  must  believe  that  recurrence  of  cartilaginous  tumors 
ensued  after  complete  removal.  In  one,  a  cartilaginous  tumor,  of  13 
years'  growth  and  9J  pounds  weight,  over  a  man's  scapula,  clavicle, 
and  neck,  returned  in  the  ribs,  and  destroyed  life  in  a  year  and  a  half. 

*  Proceedings  of  the  Pathological  Society,  ii.  344.        f  Lebert ;  Abhandlungen,  p.  101. 
X  On  Cancerous  and  Cancroid  Growths,  pp.  108  and  258. 
i   College  Museum,  No.  781. 

II  Mr.  Simon  examined  it  with  the  microscope,  and  found  it  formed  of  well-marked  car- 
tilage, with  a  fibrous  basis. 

T[  Atlas'der  pathologischen  Anatomie,  Lief  iv ;  and  Pathologische  Histologie,  p.  67. 

30 


458  MIXED    CARTILAGINOUS    TUMORS. 

In  another,  a  similar  tumor  of  the  orbit  returned  two  and  a  half  years 
after  removal.* 

We  must  conclude,  I  think,  from  these  cases,  that,  although  the 
general  rule  of  innocence  of  cartilaginous  tumors  is  established  by  their 
usual  history,  by  numerous  instances  of  permanent  health  after  re- 
moval, and  by  cases  in  which,  after  death,  no  similar  growths  are  found 
in  lymphatics  or  internal  organs,  yet  recurrence  after  operations  may 
ensue.  I  think  that  when  this  happens  it  will  generally  be  found  that 
the  recurring  growths,  if  not  the  original  growths  also,  are  soft,  rapid 
in  their  increase,  and  apt  to  protrude  and  destroy  adjacent  parts ;  as  if 
we  had,  again,  in  these,  an  instance  of  that  gradual  approximation  to 
completely  malignant  characters,  of  which  I  spoke  in  the  last  lecture. 
I  think,  too,  that  we  shall  find  that  these  soft  cartilaginous  tumors 
which  are  apt  to  recur,  or  of  which  more  than  one  exist  in  distant  parts 
in  the  same  patient,  affect  particularly  those  who  are  members  of  can- 
cerous families  (see  p.  446). 

In  connection  with  these  points,  I  may  refer  to  some  additional  facts 
in  the  pathology  of  cartilaginous  tumors. 

First,  many  may  exist  in  the  same  person ;  secondly,  they  are  some- 
times hereditary ;  thirdly,  they  may  extend  themselves  to  more  or  less 
distant  parts  by  means  of  the  lymphatics  ;t  fourthly,  they  are  not 
unfrequently  mingled  with  cancerous  growths. 

*  Virchow  relates  a  case  (Archiv,  B.  v.,  p.  216)  in  which  tumors  recurred  seven  times  in 
the  scapula,  and  were  removed  ;  an  eighth  then  grew,  and  proved  fatal.  These  tumors  con- 
tained many  cartilaginous  elements,  so  that  they  had  an  affinity  to  the  cartilaginous  group  of 
tumors ;  but  from  the  number  of  cysts  in  them  it  was  hard  to  say  with  which  they  ought  to 
be  classified. 

I  Mr.  Paget  has  recorded  in  the  Trans.  Med.  Chir.  Soc ,  vol.  xxxviii,  1855,  a  very  re- 
markable case  of  cartilaginous  tumor  of  the  right  testicle,  in  which  the  cartilage  extended 
itself  into  other  and  distant  parts  by  means  of  the  lymphatics.  It  occurred  in  a  man  set.  37. 
When  the  testicle  was  removed,  it  was  found  to  contain  tortuous,  cylindriform,  and  knotted 
pieces  of  cartilage,  some  of  which  could  be  seen  to  be  contained  in  tortuous  and  communi- 
cating canals,  which  they  tightly  filled;  others  were  close  packed,  and  imbedded  in  a  tough 
filamentous  white  connective  tissue,  but  it  is  extremely  probable  that  these  also  had  grown 
in  canals,  with  the  walls  of  which  they  had  finally  coalesced.  These  canals  were  shown 
to  be  lymphatic  vessels,  several  of  which  could  be  traced  passing  from  the  testicle  along  the 
cord,  and  containing  similar  cartilaginous  growths.  The  lymphatics  were,  by  these  growths 
within  them,  rendered  so  tortuous  and  enlarged  as  to  form  a  series  of  tumors,  like  a  chain 
of  diseased  lymphatic  glands.  Portions  of  the  lymphatic  vessels  between  the  growths  were 
dilated  into  cysts,  filled  with  a  pellucid  fluid,  probably  lymph,  detained  in  the  vessels 
through  the  obstruction  presented  by  the  growths.  The  patient  recovered  remarkably  well 
from  the  operation,  but  a  few  weeks  afterwards  he  died,  showing  signs  of  disease  in  no 
organs  but  the  lungs.  On  making  a  post-mortem  examination,  two  dilated  and  tortuous 
lymphatic  vessels  could  be  traced  upwards  from  the  internal  abdominal  ring,  along  with  the 
spermatic  bloodvessels.  They  were  filled  with  cartilage,  and  became  connected  with  a 
swelling,  along  with  which  they  adhered  closely  to  the  lower  part  of  the  vena  cava  inferior, 
reaching  nearly  to  the  origin  of  the  renal  veins.  This  swelling  was  probably  a  diseased 
lymphatic  gland.  From  one  of  the  lymphatic  vessels  above  described,  a  growth  projected 
into  the  cavity  of  the  vena  cava,  and  a  small  tuft-like  isolated  growth  of  cartilage  was  at- 
tached to  the  inner  coat  of  the  vein,  near  the  termination  of  one  of  the  renal  veins.  Ex- 
cepting these,  all  the   other  veins   examined   appeared  healthy  in  structure  and  contents. 


MIXED     CARTILAGINOUS    TUMORS.  459 

Multiplicity  is  suiEcientl  j  marked  in  the  cases  of  the  hands  and  feet, 
but  has  been  observed,  though  more  rarely,  in  other  parts ;  as  in  a  case 
recorded  by  Mr.  William  Adams,  and  already  referred  to,  as  presenting 
tumors  at  once  in  the  scapula  and  parts  of  the  humerus.  The  case  of 
Mr.  Bickersteth  (p.  446)  was  probably  of  the  same  kind. 

The  hereditary  occurrence  was  observed  in  the  case  of  a  cartilaginous 
tumor  of  the  pelvis,  of  which  I  have  already  spoken,  as  examined  by 
Mr.  Donald  Dalrymple.  The  patient's  father  had  a  large  ossified  en- 
chondroma  of  the  radius,  which  was  removed  by  Mr.  Martineau.* 

The  conjunction  of  cartilaginous  and  medullary  cancerous  tumors 
may,  perhaps,  be  called  frequent,  especially  in  the  testicle. 

A  man,  38  years  old,  was  under  Mr.  Lawrence's  care  with  an  appa- 
rent enlargement  of  one  testicle,  which  he  ascribed  to  a  blow  received 
eighteen  months  previously.  Three  weeks  after  the  blow  he  noticed  an 
enlargement,  which  regularly  increased,  and  formed  an  oval  mass  about 
four  inches  long.  This,  at  its  upper  part,  was  moderately  firm  and 
elastic ;  but  in  the  lower  third  it  felt  incompressibly  hard.  It  was  re- 
moved, and  proved  to  be  a  pale,  soft,  grayish,  medullary  cancer  in  the 
testicle,  having  in  its  lower  part  a  mass  of  cartilage,  with  scattered 
points  of  bone,  and  some  intercellular  tissue. f  The  patient  died  a 
fortnight  after  the  operation ;  and  it  was  interesting  to  observe,  as  illus- 
trating the  contrast  between  the  cartilaginous  and  the  cancerous  growths, 
that  he  had  soft  medullary  cancerous  tumors  in  the  situation  of  his  lum- 
bar lymphatic  glands,  but  no  cartilaginous  tissue  in  or  mingled  with 
them. 

The  lymphatics  also  were  not  affected  beyond  the  parts  already  described.  In  the  lungs, 
however,  cartilage  had  formed  in  very  large  quantities,  and  existed  imbedded  in  the 
healthy  pulmonary  tissue,  in  cylindriform,  or  nearly  spherical,  lobed,  and  nodular  pieces. 
In  many  of  the  larger  branches  of  the  pulmonary  artery,  small  shrub-like  growths  of  carti- 
lage, like  that  in  the  vena  cava,  were  attached  to,  without  protruding  through,  the  lining 
membrane. 

A  case  has  also  been  recorded  by  M.  Richet  (Gaz.  des  Hopitaux,  Aoiit  14,  1855)  in 
which  a  large  cartilaginous  tumor  of  the  scapula  was  removed.  The  patient  went  on  well 
for  some  time,  but  then  died  of  an  obscure  pulmonary  affection.  At  the  examination  after 
death,  a  large  number  of  tumors  were  found  in  the  lungs,  possessing  the  same  structure  as 
the  one  removed  from  the  scapula. 

We  must  admit  that  in  both  the  above  cases  a  "  generalization"  (to  employ  a  term  used 
by  some  pathologists)  of  the  cartilaginous  tumors  had  taken  place.  But  in  them  the  evi- 
dence seems  conclusive  that  the  materials  of  the  tumors  were  carried,  from  the  seat  of 
original  formation  of  the  growth,  by  the  blood  into  the  lungs,  and  served  there  as  germs  for 
the  development  of  secondary  tumors.  But  this  does  not  make  them  identical  with  malig- 
nant tumors,  in  which  the  "  generalization"  is  commonly  effected  by  causes  independent  of 
any  such  mechanical  transference  of  germs. 

*  The  specimens  are  in  the  Museum  of  the  Norfolk  and  Norwicli  Hospital.  In  the 
Edinburgh  Monthly  Journal,  vol.  xiii,  p.  195,  an  abstract  of  the  case  is  published  by  Dr. 
Cobbold,  who  relates,  in  addition  to  the  facts  I  had  learnt  from  Mr.  Thomas  Crosse,  that 
a  brother  of  the  man  who  had  the  tumor  in  the  pelvis  has  mollities  ossium,  and  that 
"  others  of  his  kindred  had  been  subjected  to  the  debilitating  influences  of  a  perverted 
nutrition." 

f  The  specimens  and  drawings  are  in  the  Museum  of  St.  Bartholomew's. 


460  MIXED    CARTILAGINOUS    TUMORS. 

A  specimen  closely  resembling  this,  and  witli  a  very  similar  history, 
is  in  the  Museum  of  the  University  of  Cambridge.  Another  is  in  the 
Museum  of  Guy's  Hospital,  of  which  it  is  said  that  the  patient  died 
with  return  of  the  medullary  disease.  Muller  noticed  the  same  com- 
bination.* Virchowf  has  cited  two  cases,  and  described  one,  all  illus- 
trating the  same  singular  fact.  In  the  three  specimens  that  I  have 
seen  of  conjunction  of  cartilaginous  and  medullary  growths  in  the 
testicle,  the  cartilage  appears  as  an  isolated  mass  in  the  substance  of 
the  medullary  tumor,  and  is  inclosed  in  a  distinct  capsule.  There 
are  other  cases,  however,  in  which  the  two  morbid  substances,  though 
distinct,  yet  lie  in  so  close  contact  that  they  are  confused  with  one  an- 
other. Thus,  in  a  tumor  which,  as  already  mentioned  (p.  444),  was 
attached  to  the  front  of  the  lumbar  vertebrse,  and  weighed  thirteen 
pounds,  half  was  formed  of  soft  flocculent  medullary  cancer,  and  half 
of  nodules  of  cartilage,  some  Avith  soft,  some  with  osseous  centres. |  A 
tumor  removed  from  over  a  woman's  parotid  gland  by  Mr.  Lloyd  was 
invested  by  a  single  capsule  of  connective  tissue ;  but  one-half  was 
cartilaginous,  and  the  other  looked  like  medullary  substance,  and  they 
were  mingled,  with  no  distinct  boundary-line,  at  their  contiguous 
borders. §  And,  lastly,  in  a  case  of  which  preparations  are  in  the  Mu- 
seum of  St.  Thomas's  Hospital,  Mr.  Dodd  removed  a  genuine  and 
apparently  unmixed  cartilaginous  tumor  from  a  man's  ribs;  but,  in 
three  months,  another  tumor  appeared  in  the  same  part,  formed  of 
closely -mingled  cartilage  and  medullary  substance.  This  quickly  proved 
fatal. 

I  need  hardly  remark  on  the  bearing  which  this  last  case  may  have 
on  the  question  of  the  recurrence  of  cartilaginous  tumors,  and  on  that 
of  the  changes  of  character  which  may  ensue  in  tumors  generally,  at 
their  successive  occasions  of  recurrence.  It  gives  to  all  these  cases  a 
much  higher  interest  than  would  attach  to  them  if  regarded  only  as 
rarities  and  strange  things. 

But  it  is  not  with  the  malignant  diseases  alone  that  cartilage  is  found 
in  tumors.  I  have  described  it  as  combined  with  what  appears  like 
glandular  tissue  in  the  tumors  over  the  parotid,  and  I  have  seen  bone 
in  similar  combination  in  a  tumor  in  the  lip.  Specimens  are  not  rare 
in  which  closely-grouped  nodules  and  irregular  masses  of  pure  white 
cartilage   are    imbedded    in    fibro-cystic  tumors  in   the   testicle. ||     In 

*  On  Cancer. 

f  Verhandl.  der  phys.-med.  Gesellschaft  in  Wurzburg,  i,  p.  1^4.  Baring  (Ueber  den 
Markschwamm  der  Hoden,  pi.  ii.)  has  represented  a  similar  specimen. 

X  Miis.  Coll.  Surg.,  207  ;  Mus.  St.  Bartholomew's,  Ser.  xxxv,  No.  49. 

§  Mus.  Coll.  Surg.,  207  A;  Mus.  St.  Bartholomew's,  Ser.  xxxv,  No.  45.  The  patient  was 
alive  at  least  seven  years  after  the  removal  of  the  tumor. 

II  Illustrative  cases  of  this  may  be  found  in  Mr.  Curling's  paper,  "  Observations  on  Cystic 
Disease  of  the  Testicle,"  Med.-Chir.  Trans.,  vol.  xxxvi,  p.  449,  and  in  a  paper  by  Billroth, 
Virchow's  Archiv,  viii,  1855. 


MYELOID     TUMORS.  461 

speaking  of  the  fibro-cellular  tumors,  I  mentioned  two  in  which  carti- 
lage was  similarly  mingled  with  their  more  essential  constituent ;  and 
in  the  Museum  of  Guy's  Hospital  is  a  tumor  removed  from  beneath  the 
gastrocnemius  muscle,  which  consists  of  both  connective  and  adipose 
tissue,  with  abundant  imbedded  nodules  of  cartilage.  And,  lastly, 
similar  combinations  appear  to  exist  of  cartilaginous  growths  with 
those  which  M.  Lebert  named  fibro-plastic,  and  which  will  be  described 
in  the  next  lecture  as  myeloid  tumors.  Such  is,  I  believe,  the  compo- 
sition of  three  tumors  in  the  Museum  of  St.  Bartholomew's,  of  which 
one  surrounds  the  head  of  the  tibia  ;*  another  involves  the  bones  of  the 
face,  and  extends  into  the  cranium  ;t  and  a  third  occupies  and  expands 
the  lower  end  of  the  fibula. |  The  compound  structure  of  the  last  was 
ascertained  with  the  microscope,  which  easily  detected  the  two  mate- 
rials irregularly  mingled  in  every  part  of  the  tumor. 

In  all  these  facts  concerning  its  combination  with  other  morbidly  pro- 
duced structures,  there  must  be  something  of  much  importance  in  rela- 
tion to  the  physiology  of  cartilage  ;  but  as  yet,  I  believe,  we  cannot 
comprehend  it.  Such  combinations  are  not,  I  believe,  imitated  in  the 
cases  of  any  other  structures  found  in  tumors  ;  even  those  that  are  thus 
combined  with  cartilage  do  not,  I  think,  combine  with  one  another,  if 
Ave  except  the  cases  of  intra-uterine  morbid  growths.  As  yet,  however, 
the  interest  that  belongs  to  all  these  inquiries  is  scarcely  more  than  the 
interest  of  mystery,  and  of  promise  to  future  investigators.  As  yet, 
we  can  think  scarcely  more  than  that,  as  innocent  tumors,  generally, 
are  remote  imitations  of  the  abnormal  excesses  of  development  which 
occur  in  embryo-life,  so  it  might  be  expected  that,  in  some  of  them, 
many  of  the  tissues  would  be  combined  in  disorder,  which,  orderly  ar- 
ranged, make  up  the  foetus. 


LECTURE    XXVII. 

PAET  I. 

MYELOID    TUMORS. 

The  Tumors  for  which  I  venture  to  propose  the  name  of  Myeloid 
(^f-ioeXwdTji;^  marrow-like),  were  first  distinguished  as  a  separate  kind  by 
M.  Lebert. §  Before  his  discovery  of  their  minute  structure,  they  were 
confounded  with  fibrous  tumors,  or  included  among  the  examples  of 
sarcoma,  and  especially  of  osteo-sarcoma.     M.  Lebert  gave  them  the 

*  Series  i,  41  ;  and  Mr,  Stanley's  Illustrations,  pi.  15,  fig.  3. 

f  Ser.  XXXV,  47  ;  and  tlie  same  lUustr.,  pi.  13,  fig.  4. 

J  Appendix  to  Pathol.  Catal. 

§  Physiologie  Pathologique,  ii,  p.  120;   and  Abhandlungen,  p.  123. 


462  MYELOID    TUMORS. 

name  of  "fibro-plastic,"  having  regard  to  their  containing  corpuscles 
like  the  elongated  cells,  or  fibro-cells,  which  he  has  called  by  the  same 
name,  and  to  which  I  have  so  often  referred  as  occurring  in  the  rudi- 
mental  fibro-cellular  and  fibrous  tumors,  and  in  developing  lymph  and 
granulations.  But  the  more  characteristic  constituents  of  these  tumors, 
and  those  which  more  certainly  indicate  their  structural  homology  (^.  e. 
their  likeness  to  natural  parts)  are  peculiar  many-nucleated  corpuscles, 
which  have  been  recognized  by  Kolliker*  and  Robinf  as  constituents 
of  the  marrow  and  diploe  of  bones,  especially  in  the  foetus  and  in  early 
life.  It  seems  best,  therefore,  to  name  the  tumors  after  this  their  nearest 
affinity.  On  similar  grounds,  they  must  be  regarded  as  having  a  nearer 
relation  to  the  cartilaginous  than  to  the  fibrous  tumors  ;  for  their  essen- 
tial structures,  both  the  many-nucleated  medulla-like  corpuscles  and 
the  elongated  cells,  are  (like  those  of  cartilaginous  tumors)  identical 
with  normal  rudimental  bone-textures.  Moreover,  as  I  have  already 
said  (p.  461),  portions  of  myeloid  structure  are  sometimes  mixed  with 
those  of  cartilaginous  tumors,  ^nd  they  are  sometimes  developed  into 
naturally  constructed  cancellous  and  medullary  bone.  The  structures 
of  this  group  of  tumors  are,  indeed,  essentially  similar  to  those  found  in 
granulations  which  grow  from,  and  may  be  transformed  into,  bone ;  and 
to  a  section  of  such  granulations  some  specimens  bear,  even  to  the  un- 
aided eye,  no  small  resemblance. 

The  myeloid  tumors  may  perhaps,  like  the  cartilaginous,  be  found  in 
other  situations  than  in  connection  with  the  bones ;  but  they  are  far 
more  frequent  in  or  upon  the  bones  than  in  any  other  tissue.  I  have 
seen  the  myeloid  structures  in  the  mammary  gland,  and  I  think  in  the 
neck,  near  the  thyroid  gland ;  and  M.  Lebert  mentions  many  other 
parts  as  occasionally  containing  tumors  belonging  to  his  "  fibro-plastic" 
group,  especially  the  eyelids  and  conjunctivse,  the  subcutaneous  tissue, 
the  cerebral  membranes,  and  the  uterus. | 

As  usually  occurring  in  connection  with  the  bones,  a  myeloid,  like  a 

*  Mikrosk.  Anatomie,  B.  ii,  pp.  364,  378. 

f  Comptes  Eendus.  .  .  .  de  la  Societe  de  Biologie,  T.  i,  p.  150;  T.  ii,  p.  8,  and  Memoirs, 
p.  143. 

J  L.  c. ;  and  in  Virchow  and  Reinbardt's  Archiv,  B  iii,  p.  463.  But  I  think  that  in  several 
of  these  instances  he  has  included  in  his  account  tumors  containing  only  the  elongated  "  fibro- 
plastic" cells;  whereas  I  have  reckoned,  as  belonging  to  this  myeloid  group  of  tumors,  none 
but  those  which,  together  with  such  cells,  contained  also  the  large  many-nucleated  corpuscles, 
which  alone  are  a  peculiar  constituent.  A  tumor  containing  elongated  fibro-cells  alone,  I 
should  expect  to  be  a  rudimental  fibro-cellular,  or  fibrous,  or  recurring  fibroid  tumor.  They 
may  also  appear  as  a  chief  constituent  in  tumors  containing  abundant  inflammatory  exuda- 
tion. M.  Lebert  communicated  an  essay  on  fibro-plastic  tumors  to  the  Societe  de  Chirurgie, 
of  which  an  abstract  is  published  in  the  Archives  Gen.  de  Medecine,  Jan.,  1853.  So  far  as 
I  can  judge  from  this  abstract,  it  is  very  advisable  to  maintain  the  distinction  which  I  have 
proposed,  between  the  myeloid  tumors,  which  are  composed  of  rudimental  bone-tissues,  and 
those  which  (whether  they  be  called  fibro-plastic,  or  by  any  other  name)  consist  of  structures 
rudimental,  of  fibro-cellular  or  fibrous  tissue-  The  anatomical  distinction  between  the  two 
groups  is  determined  by  the  presence  or  absence  of  the  many-nucleated  cells  characteristic 
of  the  myeloid  tumors. 


STRUCTURE     OF    MYELOID    TUMORS.  463 

fibrous,  tumor  may  be  either  inclosed  in  a  bone  whose  walls  are  ex- 
panded round  it,  or,  more  rarely,  it  is  closely  set  on  the  surface  of  a 
bone,  confused  with  its  periosteum.  The  sketches  in  p.  433,  of  fibrous 
tumors  within  and  upon  the  lower  jaw,  might  be  repeated  here  for 
myeloid  tumors ;  and  the  two  kinds  are  about  equally  common  in  the 
same  positions,  both  within  and  upon  the  upper  jaw.  When  inclosed 
in  bone,  the  myeloid  tumors  usually  tend  to  the  spherical  or  ovoid  shape, 
and  are  often  well-defined,  if  not  invested  with  distinct  thin  capsules  ; 
seated  on  bone,  they  are,  as  an  epulis  of  this  structure  may  exemplify, 
much  less  defined,  less  regular  in  shape,  and  often  deeply  lobed.  They 
feel  like  uniformly  compact  masses,  but  are,  in  different  instances, 
variously  consistent.  The  most  characteristic  examples  are  firm  ;  and 
(if  by  the  name  we  may  imply  such  a  character  as  that  of  the  muscular 
substance  of  a  mammalian  heart)  they  may  be  called  "fieshy."  Others 
are  softer,  in  several  gradations  to  the  softness  of  size-gelatine,  or  that 
of  a  section  of  granulations.  Even  the  firmer  are  brittle,  easily  crushed 
or  broken  ;  they  are  not  tough,  nor  very  elastic,  like  the  fibro-cellular 
or  fibrous  tumors  ;  neither  are  they  grumous  or  pulpy ;  neither  do  they 
show  a  granular  or  fibrous  structure  on  their  cut  or  broken  surfaces. 

On  section,  the  cut  surfaces  appear  smooth,  uniform,  compact,  shining, 
succulent  with  a  yellowish,  not  a  creamy,  fluid.  A  peculiar  appear- 
ance is  commonly  given  to  these  tumors  by  the  cut  surface  presenting 
blotches  of  dark  or  livid  crimson,  or  of  a  brownish  or  a  brighter  blood- 
color,  or  of  a  pale  pink,  or  of  all  these  tints  mingled,  on  the  grayish- 
white  or  greenish  basis-color.*  This  is  the  character  by  which,  I  think, 
they  may  best  be  recognized  with  the  naked  eye,  though  there  are 
diversities  in  the  extent,  and  even  in  the  existence,  of  the  blotching. 
The  tumor  may  be  all  pale,  or  have  only  a  few  points  of  ruddy  blotch- 
ing, or  the  cut  surface  may  be  nearly  all  suff"used,  or  even  the  whole 
substance  may  have  a  dull  Modena  or  crimson  tinge,  like  the  ruddy 
color  of  a  heart,  or  that  of  the  parenchyma  of  a  spleen. f 

Many  varieties  of  aspect  may  thus  be  observed  in  myeloid  tumors  ; 
and,  beyond  these,  they  may  be  even  so  changed  that  the  microscope 
may  be  essential  to  their  diagnosis.  Often,  they  partially  ossify ;  well- 
formed,  cancellous  bone  being  developed  in  them.  Cysts,  also,  vary- 
ing considerably  both  in  number  and  size,  and  filled  with  bloody  or 
serous  fluids,  may  be  formed  in  them,  occupying  much  of  their  volume, 
or  even  almost  excluding  the  solid  texture.  In  the  last  case,  the  recog- 
nition of  the  disease  is  very  difiicult.  I  lately  amputated  the  leg  of  a 
woman,  24  years  old,  for  what  I  supposed   to   be  a  cancerous  tumor 

*  Lebert  says,  the  greenish-yellow  color  that  they  may  show  depends  on  a  peculiar  sort 
of  fat,  which  he  calls  Xanthose  (Abhandl.  127). 

f  I  believe  that  many  of  what  have  been  named  spleen-like  tumors  of  the  jaws  have  been 
of  this  kind.  The  color  they  present  is  not  due  only  to  blood  in  them  ;  more  of  it  is  appro- 
priate to  their  texture,  as  that  of  the  spleen  is,  or  that  of  granulations  ;  and  it  may  be  quickly 
and  completely  bleached  with  alcohol. 


464  STRUCTURE    OF    MYELOID    TUMORS. 

growing  within  the  head  of  the  tibia.  She  had  had  pain  in  this  part 
for  eighteen  months,  and  increasing  swelling  for  ten  months ;  and  it 
was  plain  that  the  bone  was  expanded  and  wasted  around  some  soft 
growth  within  it.  On  section,  after  removal,  the  head  of  the  tibia,  in- 
cluding its  articular  surface,  appeared  expanded  into  a  round  cyst  or 
sac,  about  3|  inches  in  diameter,  the  walls  of  which  were  formed  by 
thin  flexible  bone  and  periosteum,  and  by  the  articular  cartilages  above. 
Within,  there  was  little  more  than  a  few  bands  or  columns  of  bone, 
among  a  disorderly  collection  of  cysts  filled  with  blood,  or  blood-colored 
serous  fluids.  The  walls  of  most  of  the  cysts  were  thin  and  pellucid ; 
those  of  some  were  thicker,  soft,  and  brownish-yellow,  like  the  substance 
of  some  medullary  cancers  ;  a  likeness  to  which  was  yet  more  marked 
in  a  small  solid  portion  of  tumor,  which,  though  very  firm,  and  looking 
fibrous,  was  pure  white  and  brain-like. 

None  who  examined  this  disease  with  the  naked  eye  alone  felt  any 
doubt  that  it  was  an  example  of  medullary  cancer,  with  cysts  abun- 
dantly formed  in  it.  But,  on  fninuter  investigation,  none  but  the  ele- 
ments which  I  shall  presently  describe  as  characteristic  of  the  myeloid 
tumors  could  be  found  in  it :  these,  copiously  imbedded  in  a  dimly-gra- 
nular substance,  appeared  to  form  the  substance  of  the  cyst-walls,  and 
of  whatever  solid  material  existed  between  them.  The  white  brain-like 
mass  was,  apparently,  composed  of  similar  elements  in  an  advanced 
fatty  degeneration ;  neither  in  it,  nor  in  any  other  part,  could  I  find  a 
semblance  of  cancer-cells. 

I  have  not  seen  another  specimen  deviating  so  far  from  the  usual 
characters  of  myeloid  tumors  as  this  did  ;  but  I  think  that,  as  in  this, 
so  in  any  other  variation  of  general  aspect,  the  microscopic  structures 
would  sufiice  for  diagnosis ;  for  there  is  no  other  morbid  growth,  so 
far  as  I  know,  in  which  they  are  imitated.  They  consist  essentially 
of  cells  and  other  corpuscles,  of  which  the  following  are  the  chief 
forms  : 

1.  Cells  of  oval,  lanceolate,  or  angular  shapes,  or  elongated  and  at- 
tenuated like  fibro-cells  or  caudate-cells,  having  dimly  dotted  contents, 
with  single  nuclei  and  nucleoli  (Fig.  71). 

Fiff.  71.* 


*  Fig.  71.     Microscopic  structures  of  myeloid  tumors.     A,  elongated  cells,  or  fibro-plastic 
cells  (Lebert).     B,  a  cluster  of  many-nucleated  cells.     Magnified  about  350  times. 


HISTORY    OF    MYELOID    TUMORS.  465 

2.  Free  nuclei,  such  as  may  have  escaped  from  the  cells  ;  and,  among 
these,  some  that  appear  enlarged  and  elliptical,  or  variously  angular, 
or  are  elongated  towards  the  same  shapes  as  the  lanceolate  and  cau- 
date cells,  and  seem  as  if  they  were  assuming  the  characters  of  cells. 

3.  The  most  peculiar  form ; — large,  round,  oval  or  flask-shaped,  or 
irregular  cells  and  cell-like  masses,  or  thin  disks,  of  clear  or  dimly-gra- 
nular substance,  measuring  from  g^oth  to  yo'oo^^  of  an  inch  in  diameter, 
and  containing  from  two  to  ten  or  more  oval,  clear,  and  nucleolated 
nuclei  (Fig.  71  :  see  also  Fig.  73). 

Corpuscles  such  as  these,  irregularly  and  in  diverse  proportions  im- 
bedded in  a  dimly-granular  substance,  make  up  the  mass  of  a  myeloid 
tumor.  They  may  be  mingled  with  molecular  fatty  matter  ;  or,  the 
mass  they  compose  may  be  traversed  with  filaments,  or  with  bundles  of 
connective  tissue  and  bloodvessels  ;  but  their  essential  features  (and 
especially  those  of  the  many-nucleated  corpuscles)  are  rarely  obscured. 

Respecting  the  general  history  of  the  myeloid  tumors,  the  cases 
hitherto  minutely  observed  are  too  few  and  too  various  to  justify  many 
general  conclusions.  I^ot  that  the  disease  is  a  rare  one:  for  there  can 
be  no  doubt  that  many  cases  recorded  as  examples  of  epulis,,  of  fibrous 
tumors  of  the  jaws,  of  osteo-sarcoma,  and  even  of  cancerous  growths 
about  the  bones,  should  be  referred  to  this  group.  When  these  lectures 
were  delivered  and  first  published,  no  cases  but  those  by  M.  Lebert, 
and  those  which  I  had  myself  been  able  to  observe,  were  open  to  me 
for  comparison,  but  since  that  time  the  attention  of  surgeons  and  pa- 
thologists having  been  directed  to  this  form  of  tumor,  many  additional 
cases  have  been  recorded.  From  these,  the  most  general  facts  I  can 
collect  are,  that  the  myeloid  tumors  usually  occur  singly  ;  that  they 
are  most  frequent  in  youth,  and  very  rare  after  middle  age ;  that  they 
generally  grow  slowly  and  without  pain  ;  and  generally  commence  with- 
out any  known  cause,  such  as  injury  or  hereditary  disposition.  They 
rarely,  except  in  portions,  become  osseous ;  they  have  no  proneness  to 
ulcerate  or  protrude  ;  they  seem  to  bear  even  considerable  injury  without 
becoming  exuberant ;  they  may  (but  I  suppose  they  very  rarely)  shrink, 
or  cease  to  grow  ;  they  are  not  apt  to  recur  after  complete  removal, 
although  their  recurrence  has  been  in  more  than  one  case  observed  ;* 
nor  have  they,  in  general,  any  features  of  malignant  disease,  although 
myeloid  structures  have  occasionally  been  found  mingled  with  the  ordi- 
nary structures  of  medullary  cancer,  f 

*  See  the  cases  related  in  the  note,  p.  449. 

t  Cases  by  Mr.  Cock,  in  Trans.  Path.  Soc,  viii,  389,  and  at  p.  346  of  the  same  volume  a 
case  is  related  by  Mr.  J.  Hutchinson,  in  which  the  upper  end  of  the  shaft  of  the  humerus 
and  several  enlarged  infra-axillary  glands  v^ere  removed  on  account  of  a  myeloid  tumor  of 
the  humerus.  Thickening  and  fungous  growths  appeared  a  few  weeks  after  in  the  operation 
wound,  and  five  months  after  the  operation  the  patient  died.  The  last  formed  growths  dis- 
closed well-marked  cancerous  structure,  and  several  deposits  of  soft  cancer  were  found  in 
the  right  lung. 


466  HISTORY    OF    MYELOID    TUMORS. 

I  may  illustrate  these  general  statements  by  abstracts  of  some  of  the 
cases  I  have  recorded,  selecting  for  the  purpose  those  which  were,  on 
any  ground,  the  more  remarkable.* 

A  lad,  18  years  old,  was  under  Mr.  Stanley's  care,  fifteen  years  ago, 
with  a  tumor  occupying  the  interior  of  the  symphysis,  and  immediately 
adjacent  parts  of  his  lower  jaw-bone.  It  had  been  observed  gradually 
increasing  for  eight  months  without  pain,  and  in  its  growth  had  disparted 
the  walls  of  the  jaw,  hollowing  out  a  cavity  for  itself,  and  projecting 
into  the  mouth  through  one  of  the  alveoli.  Mr.  Stanley  removed  the 
portion  of  the  jaw,  from  the  first  left  true  molar  to  the  first  right  pre- 
molar tooth.  The  tumor  presented  the  greenish  and  grayish  basis, 
blotched  with  crimson  and  various  brownish  tints,  and  the  characters 
of  firmness,  succulency,  and  microscopic  texture,  which  I  have  described 
as  most  distinctive  of  the  myeloid  tumors.  It  was  the  specimen  from 
which  some  of  the  microscopic  sketches  were  made,  and  might  be  con- 
sidered typical.  This  patient  is  still  in  good  health,  with  no  appearance 
of  return  of  the  disease. 

Mr.  Lawrence  had  under  his  care  a  woman,  21  years  old,  with  a  tu- 
mor in  the  alveolar  part  of  the  front  of  the  upper  jaw.  This  was  of 
about  twelve  months'  duration,  and  had  sometimes  been  very  painful. 
It  was  seated  in  the  cancellous  tissue  between  the  walls  of  the  alveolar 
and  adjacent  portion  of  the  upper  jaw,  projecting  slightly  into  both  the 
mouth  and  the  cavity  of  the  nose,  and  raising  their  mucous  membranes 
after  passing  through  the  wasted  bone.  After  cutting  away  the  front 
wall  of  the  jaw,  the  tumor  was  cleared  out  from  all  the  cavity  in  which 
it  lay  imbedded.  It  was  in  all  microscopic  characters  like  that  last 
mentioned,  and  resembled  it  in  general  features,  except  in  that  it  had 
in  every  part  the  dark  ruddy  color  of  a  strong  heart.  There  was  no 
reappearance  of  the  disease  for  two  years  after  the  performance  of  the 
operation,  such  as  would  have  occurred  in  the  case  of  a  malignant  tu- 
mor, if  an  attempt  had  been  made  to  remove  it  without  the  bone  in 
which  it  was  growing.  The  patient  was  then  lost  sight  of,  so  that  no 
further  history  can  be  given. 

A  woman,  22  years  old,  was  under  Mr.  Lawrence's  care,  in  March, 
1851,  from  the  alveolar  part  of  whose  right  jaw,  growths  which  were 
regarded  as  examples  of  epulis,  had  been  four  times  removed  in  the 
previous  thirteen  months.  In  the  fourth  operation,  in  August,  1850, 
the  growth  was  found  to  extend  through  the  socket  of  the  first  molar 
tooth  into  the  antrum,  or  into  a  cavity  in  the  jaw.  It  was  wholly  re- 
moved (as  it  was  thought),  and  the  wounds  healed  soundly;  but  nine 
weeks  afterwards  a  fresh  growth  appeared,  that  seemed  to  involve  or 
arise  from  nearly  the  whole  front  surface  of  the  right  upper  jaw-bone  : 
it  was  firm,  tense,  and  elastic,  but  not  painful,  projecting  far  on  the  face, 
as  well  as  into  the  nostril,  and  into  the  cavity  of  the  mouth  at  both  the 

*  The  specimens  obtained  from  all  the  following  cases  are  in  the  Museum  of  St.  Bartholo- 
mew's. 


HISTORY    OF    MYELOID    TUMORS.  467 

gum  and  the  hard  palate.  This  swelling,  under  various  treatment, 
rapidly  increased  ;  and  in  December,  1850,  a  similar  swelling  appeared 
at  the  left  canine  fossa,  and  grew  at  the  same  rate  with  that  of  earlier 
origin.  Of  course  the  coexistence  of  two  such  swellings  led  to  the  fear, 
and  in  some  minds  to  the  conviction,  that  the  disease  was  cancerous ; 
and  the  more,  because,  at  nearly  the  same  time  with  the  second  of  these, 
two  soft  tumors  had  appeared  on  the  parietal  bones.  Still,  the  patient's 
general  health  was  but  little  impaired;  and  when  the  mucous  mem- 
brane of  the  hard  palate  ulcerated  over  the  most  prominent  parts  of  the 
tumors,  neither  of  them  protruded,  or  bled,  or  grew  more  rapidly. 

In  April,  1851,  the  growth  of  the  tumors  appeared  to  be  very  much 
retarded,  and  for  the  next  month  was  hardly  perceptible  ;  and  the  pa- 
tient being  very  urgent  that  something  should  be  done  to  diminish  the 
horrible  deformity  of  her  face,  Mr.  Lawrence,  in  May,  cut  away  the 
greater  part  of  the  front  and  of  the  palatine  and  lower  nasal  parts  of 
the  right  upper  jaw,  and  removed  from  the  antrum  all  that  appeared 
morbid,  including,  doubtless,  nearly  every  portion  of  the  tumor. 

The  excised  portion  of  the  jaw-bone  was  involved  and  imbedded  in  a 
large,  irregularly  spherical  tumor,  composed  of  a  close-textured,  shining, 
soft,  and  brittle  substance,  of  dark,  grayish  hue,  suffused  and  blotched 
with  various  shades  of  pink  and  deep  crimson.  It  was  not  lobed,  but 
included  portions  of  cancellous  bone,  apparently  new-formed,  and  was 
very  closely  adherent  to  all  the  surrounding  parts.  To  the  microscope 
it  exhibited  all  the  characters  that  I  have  described  above ;  and  the 
many-nucleated  corpuscles  were  remarkably  well  defined  and  full. 
They  composed  nine-tenths  of  the  mass,  and  were  arranged  like  clus- 
tered cells.  The  patient  perfectly  recovered  from  the  effects  of  the  ope- 
ration ;  and,  to  every  one's  surprise,  the  tumor  on  the  left  upper  jaw, 
which  had  been  in  all  respects  like  that  removed  from  the  right  side, 
gradually  disappeared.  It  underwent  no  apparent  change  of  texture, 
but  simply  subsided.  The  swellings  on  the  parietal  bones,  also,  the 
nature  of  which  was  not  ascertained,  cleared  away  ;  and  when  the  pa- 
tient was  last  seen,  a  few  months  ago,  she  appeared  completely  well, 
and  no  swelling  could  be  observed. 

No  case  could  better  show  than  this  did  the  conformity  of  the  mye- 
loid tumors  with  the  general  characters  of  innocent  growths  :  on  the 
other  hand,  the  following  might  well  have  been  regarded  as  a  malignant 
disease,  if  its  structure  and  limitation  to  a  single  part  had  not  been  con- 
sidered. 

A  farmer's  boy,  15  years  old,  was  under  Mr.  Stanley's  care,  in  the 
winter  of  1851,  with  a  large  tumor  covering  the  upper  part  of  his  head, 
rising  to  a  height  of  from  one  to  two  inches  above  the  skull,  extending 
nearly  from  ear  to  ear,  and  from  the  occipital  spine  to  the  coronal  su- 
ture. This  had  been  in  progress  of  constant  growth  for  three  years, 
and  was  believed  to  have  originated  in  the  effects  of  repeated  blows  on 
the  head.    The  head  now  measured  21  inches  in  circumference,  and  16 J 


468 


HISTOEY    OP    MYELOID    TUMORS. 


inches  over  its  transverse  arch.  Just  before  his  admission  he  had  be- 
come blind  in  one  eye,  and  nearly  so  in  the  other  ;  his  gait  was  un- 
steady ;  he  had  severe  pains  in  and  about  the  forehead,  but  his  intellect 
was  not  affected,  and  he  appeared  in  good  general  health.  The  scalp 
over  the  tumor  was  exceedingly  tense,  and,  at  the  most  prominent  part, 
rather  deeply  ulcerated.  The  temporal  and  occipital  arteries  were  very 
large  and  tortuous :  the  corresponding  veins  felt  like  large  sinuses. 

In  the  last  two  months  of  his  life,  while  in  the  hospital,  his  blindness 
became  complete ;  he  lost  nearly  all  power  of  hearing,  and  suffered  se- 
vere paroxysms  of  headache.  A  large  portion  of  the  scalp  and  of  the 
subjacent  tumor  sloughed,  leaving  a  great  suppurating  cavity  in  the 
still  growing  tumor.  At  length,  two  days  before  death,  convulsions 
ensued,  which  were  followed  by  coma ;  and  in  this  he  died. 

The  tumor  covered  all  the  surface  of  the  skull  in  the  extent  above 
mentioned,  rising  gradually  from  its  circumference  to  a  height  of  two 
inches,  at  and  about  its  central  parts.  A  similar  growth  of  somewhat 
less  dimensions  existed  within  the  corresponding  parts  of  the  interior 
of  the  skull,  including  the  dura  mater  and  longitudinal  sinus,  and  deeply 
impressed  the  cerebrum.  And,  again,  material  similar  to  that  forming 
these  growths  was  infiltrated  in  and  expanded  the  included  parts  of  the 
bones  of  the  vault  of  the  skull.  From  both  surfaces  of  these  bones 
osseous  spicula  and  thin  lamellae  extended  into  the  bases  of  other  cor- 
responding parts  of  the  tumor.  The  adjacent  sketch  (Fig.  72),  from 
the  preparation  in  the  Museum  of  St.  Bartholomew's,  shows  the  rela- 
tions of  this  singular  growth  to  the  skull  and  brain,  as  seen  in  a  trans- 
verse section.   - 

The  extra-cranial  portion  of  the  tumor  had  a  nearly  uniform  dense 
and  elastic  texture,  of  dull  yellow  color,  mingled  with  white.     Its  cut 

Fig.  72. 


surface  appeared  smooth,  without  distinct  fibrous  or  other  structure, 
and  to  the  unaided  eye  looked  like  the  firmest  medullary  cancer,  in- 


HISTORY     OF    MYELOID    TUMORS. 


469 


volving  the  pericranium,  and  partially  exposed  by  ulceration  of  the 
scalp.  The  intra-cranial  portion  was  soft,  easily  crushed  and  broken 
into  pulp,  purple,  streaked  with  pale  gray  and  pink  tints.  It  looked 
obscurely  fibrous,  and  was  intersected  by  shining  bands  derived  from 
the  dura  mater  and  falx  involved  in  it.  To  the  naked  eye  it  was  like 
a  softer  medullary  tumor,  and  was  closely  connected  with  the  impressed 
surface  of  the  brain,  in  the  substance  of  which,  just  beneath  it,  was  a 
large  abscess. 

Different,  however,  as  the  two  parts  of  the  tumor  appeared,  there 
was  no  corresponding  difference  in  their  microscopic  elements ;  these 
were  essentially  the  same  in  both  parts ;  and  though  the  tumor  was  so 
like  cancer  in  its  general  aspect,  yet  its  minute  structures  were  not 
cancerous.  They  were  chiefly  as  follows :  (1)  Regular,  oval,  and  well- 
defined  cells,  about  5  Jo^h  of  an  inch  in  diameter,  containing  dimly-granu- 
lar or  dotted  substance,  in  which  many  oval  nucleolated  nuclei  were 
imbedded  (Fig.  73  a).  They  corresponded  exactly  with  the  corpuscles 
characteristic  of  the  myeloid  tumors ;  but  they  had  more  distinct  cell- 
walls  than  I  have  seen  in  any  other  case,  and  some  had  even  double 
contours,  as  if  with  very  thick  cell-walls.  (2)  Irregular  masses  or 
fragments,  of  various  sizes  and  shapes,  having  the  same  apparent  sub- 
stance as  the  contents  of  the  cells,  and  containing  similar  numerous 
imbedded  nuclei,  but  no  defined  cell-walls  (Fig.  73  b).  In  these  also, 
the  identity  with  the  constituents  of  myeloid  tumors  was  evident.  (3) 
More  abundant  than  either  of  these  forms  were  bodies  like  the  many- 
nucleated  cells,  but  having  on  their  walls,  as  it  Avere  wrapped  over 
them,  one  or  more  elongated  caudate  nucleated  cells  (c).     They  seemed 

Fis.  73.* 


to  be  formed  like  the  peculiar  corpuscles  in  epithelial  cancers,  in  which 
one  finds  cells  or  clusters  of  nuclei  invested  with  layers  of  epithelial 
scales  concentrically  wrapped  round  them.  Their  borders  presented 
two  or  three  concentric  lines,  as  if  laminated ;  between  these  were  one 
or  more  nuclei ;  and  often  the  innermost  of  the  lines  was  bayed  inwards 
towards  the  cell-cavity,  leaving  a  space  in  which  a  neucleus  was  lodged. 
Sometimes,  from  the  circumference  of  such  bodies,  one  could  find 
curved  nucleated  elongated  cells  dislodged  (d).     In  most  instances  these 


*  Fig.  73.      Microscopic  elements  of  the  myeloid  tumor  of  the  skull,  described  in  the 
text.     Magnified  350  times. 


470  HISTORY    OF    MYELOID     TUMORS. 

laminated  cells  were  filled  with  the  dimly-granular  substance  and  the 
many  nuclei ;  but  in  some  there  were  clear  spaces,  that  seemed  to  con- 
tain only  pellucid  liquid.  The  elongated  cells  that  could  be  sometimes 
detached  from  these  laminated  cells  agreed,  in  general  characters,  with 
the  remaining  principal  constituent  of  the  growth ;  namely,  (4)  narrow, 
long,  caudate  and  fusiform  cells  with  outswelling  nuclei,  like  those  of 
developing  granulations,  and  such  as  I  have  described  as  constant  ele- 
ments of  the  myeloid  tumors. 

All  the  minute  structures  just  described  were  found  closely  compacted, 
and  making  up  with  free  nuclei  and  granular  matter  the  mass  of  both 
portions  of  the  tumor ;  and  the  only  apparent  diiference  was,  that  in  the 
intra-cranial  portion,  they  appeared  more  generally  to  contain  granules, 
and  to  be  mixed  with  granule-cells  and  granule-masses,  as  if  this  part 
of  the  tumor  were  more  degenerate  than  the  other. 

I  fear  that  even  so  abbreviated  a  record  of  this  case  as  I  have  ven- 
tured to  print  may  seem  very  tedious ;  but  it  is  not  for  its  own  rarity 
alone  that  the  case  is  important.  It  would  be  diflScult  to  find  a  tumor 
more  imitative  of  cancer  than  this  was  in  its  mode  of  growth,  its  infil- 
tration of  various  tissues,  its  involving  of  important  parts,  its  apparent 
dissimilarity  from  any  natural  structures.  And  yet  it  certainly  was  not 
cancer ;  the  microscopic  elements  were  like  those  of  natural  parts :  not 
a  lymphatic  or  any  other  organ  was  afl"ected  by  a  similar  disease,  and 
death  seemed  to  be  due  solely  to  the  local  effects  of  the  growth.* 

But  while  these,  and  many  other  cases,  may  be  enough  to  prove  that 
the  myeloid  tumors  are  generally  of  innocent  nature,  yet  I  suspect  cases 
may  be  found  in  which,  with  the  same  apparent  structures,  a  malignant 
course  is  run.     Of  such  suspicious  cases  the  two  following  are  examples : 

A  woman,  50  years  old,  was  under  Mr.  Stanley's  care,  in  1847,  with 
an  irregular,  roundish,  heavy  tumor,  between  two  and  three  inches  in 
diameter,  in  her  left  breast.  It  projected  in  the  breast,  and  the  skin 
over  it  was  red  and  tense,  and  at  one  part  seemed  to  point,  as  if  with 
suppuration.     Some  axillary  glands  were  enlarged,  but  not  hardened. 

This  tumor  had  existed  about  nine  months,  had  been  the  seat  of 
occasional  pain,  and  was  increasing.  It  was  considered  to  be  hard 
cancer;  but,  on  the  removal  of  the  breast,  was  found  to  be  a  distinct 
growth,  completely  separable  from  the  mammary  gland,  which  was 
pressed  aside  by  it.  Its  character  was  obscured  by  suppuration  in 
many  points  of  its  substance ;  yet,  after  a  careful  examination  of  it  in 
the  recent  state,  and  a  repeated  examination  of  the  notes  and  sketches 
that  I  made  of  its  structure,  I  can  only  conclude  that  it  was  a  myeloid 
tumor  suppurated,  or,  possibly,  mingled  with  cancer. 

Eighteen  months  after  the  removal  of  her  breast,  this  patient  returned 

*  A  collection  of  cases  of  myeloid  tumors,  several  of  which  occurred  in  the  practice  of 
Sir  B.  Brodie,  by  Mr.  H.  Gray,  may  be  found  in  Med.-Chir.  Trans.,  vol.  xxxix,  1856;  and  in 
the  Trans.  Path.  Soc,  vol.  vii,  are  other  cases  related  by  Dr.  Bristowe,  Mr.  C.  Havi^kins,  and 
Mr.  B.  Childs. 


HISTORY  OF  MYELOID  TUMORS.  471 

to  the  hospital,  with  a  large  ulcerated  tumor  in  the  lower  part  of  her 
left  axilla,  which  had  begun  to  form  as  a  distinct  tumor  six  months  after 
the  operation.  This  was  like  a  large  flat  ulcerated  cancer  :  it  often 
bled  freely.  Her  general  health  was  deeply  affected  by  it,  and  she 
died  in  two  or  three  months  after  her  readmission. 

The  malignant  character  manifested  in  this  case  was  yet  more  de- 
cidedly marked  in  another.  A  man,  53  years  old,  of  healthy  appear- 
ance, was  under  Mr  LaAvrence's  care,  with  an  oval  tumor,  extending, 
under  the  mastoid  muscle,  from  the  angle  of  the  jaw  to  the  clavicle. 
Bloody  serum  oozed  from  it  through  three  small  apertures  in  the  in- 
teguments. The  anterior  part  of  the  tumor  felt  as  if  containing 
fluid;  the  posterior  part  felt  solid,  firm,  and  elastic.  He  had  observed 
this  tumor  for  ten  months,  having  found  one  morning,  when  he  awoke, 
a  lump  nearly  as  large  as  an  egg,  which  regularly  increased.  In  two 
months  it  had  become  very  large :  it  was  punctured,  and  about  one-third 
of  a  pint  of  reddish  serum  was  discharged  from  it.  In  the  succeeding 
eight  months  it  was  tapped  thirty-four  times  more,  about  the  same  quan- 
tity of  similar  fluid  being  each  time  evacuated.  It  was  also  six  times 
injected  with  tincture  of  iodine,  twice  traversed  with  setons,  and  in 
various  other  ways  severely  treated.  The  only  general  result  was,  that 
it  increased,  and  seemed  to  become,  in  proportion,  more  solid.  When 
admitted  under  Mr.  Lawrence,  all  the  parts  over  the  tumor  were  ex- 
tremely tense  and  painful,  and  cerebral  disturbance  appeared  to  be 
produced  by  its  pressure  on  the  great  bloodvessels  of  the  neck.  It  was 
freely  cut  into,  and  the  surface  which  was  exposed  presented  well- 
marked  characters  of  the  myeloid  tumors  such  as  I  have  described. 
Some  small  portions  that  were  removed  enabled  me  to  conflrm  this  with 
the  microscope.  The  elongated,  and  the  many-nucleated  cells,  were, 
to  all  appearance,  decisive.  The  incision  of  the  tumor  produced  tem- 
porary relief;  but  the  tumor  continued  to  grow,  and  death  occurred 
nearly  twelve  months  from  its  commencement.  In  examination  after 
death,  the  solid  portion  of  the  tumor  formed  five-sixths  of  its  bulk,  the 
rest  consisting  of  a  suppurating  cavity.  The  microscopic  characters  of 
the  solid  part  were  exactly  like  those  of  the  portions  removed  during 
life,  though  the  substance  appeared  firmer  and  whiter  than  before,  and 
yielded,  when  scraped,  a  creamy  fluid.  Four  small  masses  of  similar 
substance  were  found  in  the  lungs ;  and  a  similar  material  was  diffused 
in  one  cervical  gland.* 

Now  in  both  these  cases,  and  especially  in  the  last,  the  whole  history 
of  which  seems  full  of  anomalies,  there  were  certainly  such  features  of 

*  In  the  Trans.  Path.  Soc,  vol.  ix,  p.  367,  a  case  is  communicated  by  Mr.  Henry,  in  which 
a  myeloid  tumor,  the  size  of  an  orange,  was  removed  by  amputation  through  the  shoulder- 
joint.  Some  six  weeks  afterwards  a  rapidly-growing  recurrent  tumor  appeared.  The 
patient  died  three  months  after  the  operation.  The  recurrent  tumor  contained  the  charac- 
teristic myeloid  bodies.  Secondary  myeloid  deposits  were  found  in  both  lungs.  See  also  a 
case  by  Dr.  Wilks,  in  vol.  x,  p.  244,  which  is  again  referred  to  in  a  note  on  p.  577. 


472  OSSEOUS    TUMORS. 

dissimilarity  from  the  usual  general  characters  of  the  myeloid  tumors, 
that,  although  the  microscopic  characters  appeared  identical,  yet  they 
are  not  enough  to  prove  even  the  occasional  malignancy  of  the  disease : 
they  are  enough  to  make  us  cautious  ;  enough  to  induce  us  to  study 
this  disease  very  carefully,  as  one  of  those  that  may,  in  different  con- 
ditions, or  in  different  persons,  pursue  very  different  courses  ;  appearing 
in  some  as  an  innocent,  in  others  as  a  malignant  disease.  The  use  of 
such  terms  as  "semi-malignant,"  "less  malignant  than  cancer,"  and 
the  like,  in  relation  to  growths  of  this  kind,  involves  subjects  of  singu- 
lar interest  in  pathology,  as  well  as  in  practical  surgery.  But  I  will 
not  now  dwell  on  them.  The  whole  subject  may  be  more  appropriately 
discussed  in  the  lectures  on  malignant  tumors. 


LECTURE    XXVII. 

PAET  II. 

OSSEOUS  TUMORS. 

Much  of  the  general  pathology  of  osseous  tumors  has  been  considered 
in  the  last  two  lectures,  which  have  treated  of  the  tumors  composed  of 
rudimental  bone-textures.  Ossification  may  ensue  in  either  a  cartila- 
ginous or  a  myeloid  tumor.  In  the  latter  it  is  rarely,  if  ever,  more 
than  partial,  in  the  former  it  may  be  complete ;  and  the  cartilaginous 
may  be  transformed  into  an  osseous  tumor.  The  name  of  osseous  tu- 
mor is,  however,  not  usually  applied  to  those  in  which  ossification  is  in 
progress.  It  is  reserved  for  such  as  are  formed  wholly  of  bone :  and 
of  these  I  shall  now  chiefly  speak. 

Osseous  tumors,  even  more  generally  than  cartilaginous,  are  con- 
nected with  the  bones,  with  which,  moreover,  though  they  may  have 
the  other  characters  of  tumors,  they  are  almost  always  continuous,  after 
the  manner  of  outgrowths.  They  are,  hoAvever,  occasionally  found  in 
soft  parts,  as  distinct  and  discontinuous  tumors,  invested  with  capsules 
of  connective  tissue.  Thus  in  the  College  Museum  (No.  203)  is  a  small, 
completely  osseous,  tumor,  formed  of  soft  cancellous  tissue  with  me- 
dulla, which  lies  over  the  dorsal  surface  of  the  trapezial  and  scaphoid 
bones,  completely  isolated  from  them  and  all  the  adjacent  bones.  In 
the  Museum  of  St.  George's  Hospital  is  a  tumor  formed  of  compact 
bony  tissue,  which  lay  over  the  palmar  aspect  of  the  first  metacarpal 
bone,  loosely  imbedded  in  the  areolar  tissue,  and  easily  separated  from 
the  flexor  tendons  of  the  finger.*     It  had  been  growing  five  years  in  a 

*  An  account  of  it  is  reported  in  the  Medical  Times,  Aug.  3,  1850. 


OSSEOUS    TUMORS.  473 

middle-aged  woman.  So,  but  rarelj  and  imperfectly,  the  cartilaginous 
tumors  over  the  parotid  gland  are  ossified  ;*  and  those  in  the  lungsf 
and  testicle. 

At  present,  these  isolated  osseous  tumors  are  interesting  for  little 
more  than  their  rarity.  It  is  to  those  connected  with  bones  that  I  must 
now  particularly  address  myself. 

I  have  already  said  that  these  have  the  character  of  continuous 
growths ;  that  they  are  like  outgrowths  rather  than  tumors.  And  it  is 
not  easy  to  draw  any  line  of  distinction  between  what  deserve  to  be 
considered  as  tumors,  and  such  accumulations  of  bone  as  may  ensue  in 
consequence  of  superficial  inflammation,  or  other  disease,  of  the  bone 
or  periosteum.  The  exostoses  and  hyperostoses  of  nosology  are  not  to 
be  severally  defined  without  artifice ;  but,  in  general,  we  may  take  this 
as  a  convenient,  and  perhaps  a  just,  method  of  dividing  them :  namely, 
that  those  may  be  reckoned  as  osseous  tumors,  or  outgrowths  of  the 
nature  of  tumors,  whose  base  of  attachment  to  the  original  bone  is  de- 
fined, and  groAvs,  if  at  all,  at  a  less  rate  than  their  outstanding  mass.| 
Those  which  are  not  of  the  nature  of  tumors  are  generally  not  only  ill- 
defined,  but  widely  spread  at  their  bases  of  attachment;  and  the  addi- 
tions made  to  them  increase  their  bases  rather  than  their  heights  or 
their  whole  masses. 

Of  osseous  tumors,  thus  roughly  defined,  two  chief  kinds  may  be 
observed ;  namely,  the  cancellous,  and  the  compact  or  ivory-like,  which, 
speaking  generally,  may  be  said  to  resemble  respectively  the  medullary 
tissue,  and  the  walls  or  compact  substance,  of  healthy  bone.  In  both 
alike,  the  bone  is  usually  true  and  good  bone.  By  my  own  observations 
of  it  I  know  no  more  than  this  ;  but  Mr.  Quekett,  who  has  submitted 
to  microscopic  examination  portions  of  all  the  osseous  tumors  in  the 
College  Museum,  confirms  the  general  statement  in  all  particulars.  In 
difi"erent  specimens  there  may  be  varieties  in  the  proportion  and  ar- 
rangement of  bloodvessels,  and  in  the  size  and  development  of  the 
bone-corpuscles  or  lacunae  and  their  canals ;  but  the  proper  characters 
of  the  bone  of  the  species  in  which  the  tumor  occurs  are  not  far  de- 
parted from. 

I  believe  the  homology  of  the  osseous  tumors  is,  in  chemical  quali- 
ties, as  perfect  as  it  is  in  structure  ;  and  that,  as  with  the  natural 
bones,  so  with  these,  we  may  not  ascribe  diff"erences  of  hardness  or  den- 
sity to  the  different  proportions  of  the  organic,  and  of  the  saline  and 
earthy  components ;  but  to  the  difi'erent  manner  in  which  the  similar 
material  that  they  compose  is,  in  difi'erent  specimens,  compacted.  Their 
varieties  of  hardness  depend  on  mechanical  rather  than  on  chemical 
diff"erences. 

Of  the  general  methods  of   ossification   of   cartilaginous   tumors  I 

*  Mus,  Coll.  Surg.,  No.  204.  f  Museum  of  St.  Thomas's  Hospital. 

X  Mr.  Stanley  particularly  remarks  this  in  relation  to  operations  for  removal  of  exostoses 
(On  Diseases  of  the  Bones,  p.  150). 

31 


474  OSSEOUS    TUMORS. 

spoke  in  my  last  lecture,  and  then  noticed  that  in  nearly  all  cases  when 
the  ossification  of  the  tumors  is  completed,  they  consist  of  a  very  thin 
laver  or  wall  of  compact  tissue,  covering  in  a  mass  of  cancellous  and 
medullary  substance :  and  thus  they  are  composed,  ivhether  the  carti- 
lage growth  began  within  or  upon  the  bone.  It  is  probable  that,  in 
some  instances,  the  hardest  osseous  tumors  may  be  also  formed  by 
transformation  of  cartilage  into  bone.  Thus,  an  exceedingly  hard, 
ivory-like  tumor  at  the  angle  of  the  lower  jaw,  in  the  Museum  of  the 
College,*  has  so  exactly  the  nodular  and  irregular  spheroidal  shape  be- 
longing to  cartilaginous  tumors,  and  to  the  rare  cancellous  bony  tumors 
in  the  same  part,  that  we  can  scarcely  doubt  it  had  a  primordial  carti- 
laginous condition.  So,  too,  Professor  Goodsir  tells  me,  there  is  in  the 
Museum  of  the  University  of  Edinburgh  a  tumor  of  the  humerus  (573) 
removed  by  Mr.  Syme,  which  is  in  its  interior  in  part  hard  and  com- 
pact like  ivory,  whilst  its  surface  is  nodular  and  irregularly  spheroidal, 
and  covered  by  a  layer  of  cartilage. f  In  the  Museum  of  Guy's  Hos- 
pital there  is  a  somewhat  similar  specimen ;  in  which,  however,  the  hard- 
ness of  the  bone  may  be  due  to  inflammatory  induration  of  an  ordinary 
cancellous  osseous  growth. 

*  No.  1035;  it  may  be  compared  with  a  cancellous  tumor  of  the  same  form,  in  the  Mu- 
seum at  St.  George's  Hospital,  removed  by  Mr.  Tatum. 

t  In  a  paper  on  pedunculated  exostosis  of  the  long  bones,  in  the  Ed.  Med.  Journ.,  Jan., 
1854,  Mr.  Syme  records  the  removal  of  a  similar  exostosis  from  the  neck  of  the  humerus  ; 
and  at  p.  7  of  the  same  number  of  the  Journal,  an  account  of  the  structure  of  the  tumor  is 
given  by  Mr.  Lister.  The  surface  of  this  tumor  was  irregularly  nodulated,  and  in  part 
covered  by  cartilage.  Beneath  the  cartilaginous-covered  prominences  there  was  a  consider- 
able thici£ness  of  a  peculiar  white  compact  substance,  too  gritty  and  friable  for  bone,  which 
proved  to  be  calcified  cartilage,  and  as  a  general  rule  this  calcified  cartilage  was  present  in 
the  greatest  amount  where  the  cartilaginous  covering  was  the  thickest.  In  the  more  circum- 
ferential parts  of  the  tumor,  where  no  cartilage  existed,  loose  cancellous  tissue  extended 
close  to  the  surface,  which  was  formed  by  a  thin  layer  of  compact  tissue.  The  deeper  sur- 
face of  the  calcified  cartilage  presented  many  excavations,  into  which  processes  of  medul- 
lary substance  and  spicula  of  cancellous  bone  extended.  The  conclusion  which  Mr.  Lister 
draws  from  the  examination  is,  that  the  exostosis  grew  as  cartilage,  and  that  in  its  conver- 
sion into  cancellated  bone,  the  stage  of  calcification  of  cartilage  occupied  a  very  prominent 
position. 

Corresponding  closely  with  the  above,  in  their  mode  of  growth  at  least,  appear  to  be  those 
cases  described  by  Virchow  (Entwick.  des  Schadelgrund  :  Berlin,  1857,  p.  51,  e.  s.),  in 
which  small  exostoses  projected  from  the  upper  surface  of  the  os  basilare  into  the  cavity  of 
the  skull.  They  were  limited  in  size,  and  grew  from  the  clivus,  at  the  synostosis,  between 
the  occipital  and  sphenoidal  portions  of  the  basilar  process.  They  were  evidently  growths 
from,  the  cartilage,  which  originally  connects  these  bones  together,  and  ossification  had  taken 
place  in  them,  just  as  in  the  normal  bones.  In  some  cases  a  thin  layer  of  cartilage  still  re- 
mained on  the  surface  of  the  exostosis.  Virchow  has  found  in  some  of  these  cases,  small 
gelatinous  tumors  of  the  size  of  a  pea  or  cherry,  connected  to  the  exostosis  by  means  of  a 
pedicle,  projecting  through  the  dura  mater,  and  resting  against  the  anterior  margin  of  the 
pons  varolii,  close  to  the  place  of  division  of  the  basilar  artery.  On  microscopic  examina- 
tion, they  were  found  to  consist  partly  of  bladder-like  cells,  similar  to  those  which  he  had 
already  described  in  cancer,  as  Physaliphores  (Archiv.  iii,  p.  197),  and  partly  of  an  inter- 
mediate substance,  like  the  mucous  tissue  of  the  vitreous  body,  which  gradually  passed  into 
the  large-celled  cartilage  covering  the  surface  of  the  exostosis.  Virchow  has  termed  this 
form  of  mucous  tumor,  ecchondrosis  prolifera.  Additional  cases  have  been  recorded  by 
Luschka  (Virchow's  Archiv.  vol.  xi,  1857)  and  Zenker  (lb.,  vol.  xii,  1857). 


OSSEOUS    TUMORS.  475 

These,  however,  are  probably  exceptions  to  the  general  rule  concern- 
ing the  compact  or  ivory  exostoses;  for,  for  the  majority  of  these,  Ro- 
kitansky  says  truly  that  no  preparatory  cartilage  is  formed.  As,  in 
the  natural  ossification  of  the  skull,  the  bone  is  formed,  not  in  a  matrix 
of  cartilage,  but  in  fibrous  tissue,  layers  of  which  are  successively  ossi- 
fied, so  probably  are  the  hard  bony  tumors  of  the  skull  formed. 

The  general  characters  of  the  cancellous  bony  tumors  are  so  nearly 
described  in  the  account  of  the  cartilaginous  tumors  from  which  they 
commonly  originate,  that  I  need  only  briefly  refer  to  them.  They 
usually  afi"ect  a  round  shape,  with  projecting  lobes  or  nodules,  which 
answer  to  those  of  the  conglomerate  cartilaginous  tumors,  and  are  often 
pointed  or  angular.  They  may,  however,  be  very  smooth  on  their  sur- 
face, whether  they  have  grown  within  bones,  whose  extended  walls  form 
now  their  outer  layer,  or  without  them  on  the  periosteum.  When  com- 
pletely ossified,  their  respective  tissues,  compact  and  medullary,  are 
usually  continuous  with  those  of  the  bone  on  which  they  are  planted ; 
and  the  later  periods  of  growth  seem  attended  with  such  mutual  adapta- 
tion as  may  tend  towards  making  one  continuous,  though  deformed,  mass 
of  the  old  and  the  new  bone. 

The  singularities  of  position  in  which  the  osseous  tumors  may  be 
found,  and  the  important  hindrances  that  may  result  from  their  inter- 
ference with  adjacent  parts,  I  need  not  fully  detail;  they  are  amply 
enumerated  by  Mr.  Stanley.  But  it  may  not,  perhaps,  be  uninterest- 
ing to  say  a  few  words  respecting  those  osseous  tumors  which  not  unfre- 
quently  grow  at  the  attachment  of  tendons,  especially  at  the  lower  end 
of  the  femur,  a  little  above  the  inner  condyle,  close  to  the  insertion  of 
the  adductor  magnus.*  These  tumors  are  peculiarly  apt  to  acquire  a 
narrow  pedunculated  base  of  attachment.  In  these  cases  one  usually 
finds  a  layer  of  cartilage  incrusting  some  cancellous  and  medullary  bone, 
and  the  bone  as  a  narrow  pedicle  extends  into  continuity  with  the  wall 
on  the  cancellous  tissue  of  the  subjacent  shaft.f  Such  tumors  have  then 
the  characters  of  polypoid  outgrowths  from  the  bone,  and  may  be  treated 
accordingly,  for,  when  cut  or  broken  off,  their  stems  will  not  grow. 
Indeed,  that  stem  may  chance  to  be  unwittingly  broken ;  as  in  a  tumor 
removed  by  Mr.  Lawrence. |  It  had  grown  on  the  inner  and  lower 
part  of  the  femur,  and,  when  fairly  exposed,  was  easily  detached  with- 
out further  cutting:  the  narrowest  part  of  its  stem  rested  in  a  slight 
depression  in  the  femur,  but  had  no  connection  by  tissue  with  it.  It 
seemed  as  if  the  narrow  pedicle  of  a  tumor,  two  inches  in  diameter,  had 
been  by  accident  broken  oif,  and  the  friction  of  the  broken  surfaces  had 
smoothed  and  fitted  them  together. 

*  Mr.  Syme  (op.  cit.  p.  5)  records  a  case  in  which  he  removed  one  of  these  peduncu- 
lated exostoses  from  the  outer  side  of  the  thigh  bone. 

f  A  very  ilhistrative  figure  of  this  pedunculated  form  of  osseous  tumor  is  given  in  Druitt's 
Surgery,  p.  214,  5th  ed. 

X  Mus.  St.  Bartholomew's,  Ser.  i,  183. 


476  lYORY-LIKE     OSSEOUS    TUMORS. 

Of  their  rates  of  growth  little  is  known ;  but  I  believe  that  when  a 
cartilaginous  tumor  is  completely  ossified,  the  growth  of  the  bony  tumor 
is  extremely  slow.  However,  osseous  tumors  may  be  found  of  an  enor- 
mous size.  The  largest  that  I  know  is  in  the  Museum  of  the  College.* 
It  nearly  surrounds  the  upper  two-thirds  of  a  tibia,  in  an  irregularly 
oval  mass,  with  a  nodulated  surface,  almost  entirely  covered  in  by  a 
thin  layer  of  compact  tissue,  and  cancellous  in  all  its  interior.  It 
measures  exactly  a  yard  in  circumference,  and  the  limb,  which  was  am- 
putated by  Mr.  Gay,  a  former  surgeon  of  St.  Bartholomew's  Hospital, 
weighed  forty-two  pounds. 

Another  tumor  of  large  size  is  in  the  Museum  of  the  same  Hospital. f 
A  great  nodulated  mass  of  bone  is  attached  to  the  ischium  and  pubes, 
and  formed  part  of  a  tumor  of  which  the  rest  was  nodulated  cartilage. 

The  compact,  hard,  or  ivory-like  bony  tumors  occur,  especially,  about 
the  bones  of  the  head,  and  present  several  diversities  of  form.  Some 
are  uniform  and  simple;  others -variously  lobed,  or  nodular.  The  simple 
tumors  are  commonly  attached  to  the  skull  by  narrowed  bases,  over 
which  their  chief  masses  are  prominent  on  one  side,  or  all  round.  A 
good  specimen  of  this  kind  is  in  the  Museum  of  St.  Bartholomew's  Hos- 
pital,! Avhich  shows,  besides,  that  these  tumors  may  consist  of  an  exte- 
rior hard,  and  interior  cancellous,  tissue,  respectively  resembling  and 
continuous  with  the  outer  table  and  the  diploe  of  the  skull.  Some  of 
these  hard  tumors  have  the  shape  of  biconvex  lenses,  resting  with  one 
convex  surface  on  the  skull,  or  like  a  nut  bisected,  the  flat  surface  being 
in  contact  with  the  skull ;  and  of  such  as  these  more  than  one  may  be 
found  on  the  same  skull.  § 

A  disease  much  more  formidable  than  these  exists  in  the  nodulated 
and  larger  hard  osseous  tumors  connected  with  the  bones  of  the  skull. 
These  are  not  like  outgrowths  from  the  outer  table  and  diploe  ;  for 
they  often,  or  I  believe  usually,  grow  first  between  the  tables  of  the 
skull,  or  in  the  cavities  of  the  frontal  or  other  sinuses.  Increasing  in 
these  parts,  they  may  tend  in  every  direction,  penetrating  the  tables  of 
the  skull,  and  forming  large  masses,  projecting  as  much  into  the  interior 
of  the  skull  as  on  its  exterior. 

The  most  frequent  seat  of  such  tumors  is  in  the  frontal  bone,  espe- 
cially about  its  superciliary  and  orbital  parts  ;  and  they  are  horrible 
by  their  pressure  into  the  cavities  of  both  the  cranium  and  the  orbit, 
compressing  the  brain,  and  protruding  one  or  both  eyes. 

The  characters  of  the  disease,  so  far  as  the  growth  is  concerned,  are 
well  shown  in  a  huge  mass  which  grew  from  the  forehead   of   an  ox, 

*  No.  3220.  It  is -engraved  in  Cheselden"s  Osteograpliea,  Tab.  53,  f.  1,  2,  3.  A  painting 
of  it  is  in  the  St   Bartholomew's  Museum. 

t  Series  1  a,  No.  133;  and  Series  1,  No.  118. 

J  Series  1,  71.  Series  1  A,  124,  in  the  same  Museum,  and  No.  321-5  in  the  Museum  of  the 
College,  are  nearly  similar  specimens. 

f  Mus.  Coll.  Surg.,  793.     See  also  Miller's  Principles  of  Surgery,  p.  447,  ed.  1853. 


IVORY-LIKE    OSSEOUS    TUMORS. 


477 


originating  apparently  in  the  frontal  sinuses.*  It  is  like  a  great  sphe- 
roidal mass  of  ivory,  measuring  SJ  inches  in  diameter,  and  weighing 
upwards  of  sixteen  pounds.  Its  outer  surface,  though  knobbed  and 
ridged,  is  yet  compact,  like  an  elephant's  tusk  ;  and,  in  similar  likeness, 
its  section  shows  at  one  part  a  thin  investing  layer,  like  the  bone  cover- 
ing the  ivory.  It  is  nearly  all  solid,  hard,  close-textured,  and  heavy  ; 
only  a  few  irregular  cavities,  and  one  with  smooth  walls,  appear  in  its 
interior,  and  you  may  trace  the  orifices  of  many  canals  for  bloodvessels. 
Mr.  Quekett  found  that  this  tumor  had  a  higher  specific  gravity  than  any 
bone,  except  that  which  is  found  in  what  are  called  the  porcellaneous 
deposits,  or  transformations,  in  the  heads  of  bones  affected  with  chronic 
rheumatism.     But  it  has  in  every  part  the  structure  of  true  bone. 

Just  like  this,  in  the  general  characters  of  their  tissue,  are  the  hard 
bony  tumors  from  the  human  frontal  bone.  In  one,  an  Hunterian 
specimen, t  such  a  tumor,  2|  inches  in  diameter,  deeply  lobed  and 
knotted,  fills  the  frontal  sinuses  and  the  upper  part  of  the  left  orbit, 
encroaches  into  the  right  orbit,  and  projects  for  nearly  an  inch  on  both 
the  surfaces  of  the  skull.  It  appears  to  have  originated  in  the  ethmoidal 
or  frontal  cells,  and,  in  its  growth,  to  have  displaced  and  destroyed  by 
pressure  the  adjacent  parts  of  the  tables  of  the  skull  and  the  wall  of 
the  orbit.  It  is,  for  the  most  part,  as  hard  as  ivory,  but  in  its  central 
and  posterior  portion  is  composed  of  very  close  cancellous  tissue. 

A  specimen,  far  surpassing  this  in  size,  but  resembling  it  in  all  its 
general  characters  and  relations,  is  in  the  Museum  of  the  University  of 
Cambridge,  and  is  represented  in  Fig.  74.  It  is  the  largest  and  best 
specimen  of  the  kind  that  I  have  seen,  and  its  osseous  structure  is  dis- 
tinct ;  only  as  Professor 

Clark  has  informed  me,  -^^^-  ''^■^ 

it  is  irregular :  in  the 
hardest  parts  there  are 
neither  Haversian  ca- 
nals nor  lacunge  ;  in  the 
less  hard  parts,  the 
canals  are  very  large, 
and  the  lacunse  are  not 
arranged  in  circles 
around  them :  and 
everywhere  the  lacunae 
are  of  irregular  or  dis- 
torted forms. 

A  smaller  specimen 
is  in  the  Museum  of  St. 


*  Mus.  Coll.  Surg.,  3216. 

f  Mus.  Coll.  Surg.,  795.     It  is  engraved  in  Baillie's  Morbid  Anatomy,  Fasc.  x,  pi.  1,  fig 
2;  and  in  Home,  Philosoph.  Trans.,  vol.  Ixxxix,  p.  239. 

J  Fig.  74.     Hard  bony  tumor  of  the  skull :  from  the  Cambridge  University  Museum. 


478  OSSEOUS    OVERGROWTHS. 

Bartholomew's  Hospital.  A  girl,  20  years  old,  was  admitted  with  pro- 
trusion of  the  left  eyeball,  which  appeared  due  to  an  osseous  growth  pro- 
jecting at  the  anterior,  upper,  and  inner  part  of  the  orbit.  None  but  the 
anterior  boundaries  of  this  growth  could  be  discerned.  It  had  been  ob- 
served protruding  the  eye  for  three  years,  and  had  regularly  increased  ; 
it  was  still  increasing,  and  produced  severe  pain  in  the  eyeball,  and 
about  the  side  of  the  head  and  face.  It  seemed,  therefore,  necessary  to 
attempt  the  removal  of  the  tumor,  or  at  least  to  remove  some  part  of  it, 
with  the  hope  that  the  disturbance  of  its  growth  might  lead  to  its  necrosis 
and  separation.  A  portion  of  it  was  with  great  difficulty  sawn  off;  but 
the  patient  died  with  suppuration  in  the  membranes  of  the  anterior  part 
of  the  cerebrum. 

Now  all  these  cases,  corroborated  as  they  are  by  others  upon  record, 
prove  the  general  character  and  relations  of  these  tumors.  Their 
nodular  form,  and  uniform  hard,  ivory-like  texture  ;  their  growth  in  the 
diploe  or  sinuses,  as  isolated  or  narrowly  attached  masses ;  their  ten- 
dency to  extend  in  all  directions ;  their  raising  and  penetrating  the 
bones  of  the  skull,  and  growing  into  the  cavities  of  the  skull  and  orbit ; 
all  show  the  exceeding  difficulty  and  peril  of  operations  on  them.  The 
simpler  kinds,  that  only  grow  outwards,  may  indeed  be  cut  off  with 
advantage,  though  seldom  without  great  difficulty ;  and,  often,  the 
attempt  to  remove  them  has  been  made  in  vain ;  but  these  larger  and 
nodular  tumors  about  the  brow  can  very  rarely  be  either  cut  off  or 
extirpated.* 

The  extirpation,  however,  which  may  be  impossible  for  art,  is  some- 
times effected  by  disease :  these  tumors  are  occasionally  removed  by 
sloughing.  Such  an  event  happened  in  a  case  related  by  Mr.  Hilton  ;f 
and  the  great  ivory-like  mass,  clean  sloughed  away,  is  in  the  Museum 
at  Guy's.  So,  too,  in  a  case  by  Mr.  Lucas,  a  bony  tumor  at  the  edge 
of  the  orbit,  after  growing  eight  months,  was  exposed  by  an  incision 
through  the  upper  eyelid.  The  wound  did  not  heal ;  the  tumor  con- 
tinued to  grow;  and,  twelve  months  afterwards,  it  became  "carious," 
and  was  detached.  The  course  of  treatment  which  these  cases  suggest 
has  been,  I  believe,  the  only  one  worth  imitation ;  namely,  exposure  of 
the  tumor,  and  application,  if  need  be,  of  escharotics  to  the  surface  of 
the  bone. 

These  hard  osseous  tumors  are  very  rarely  found  in  connection  with 
any  bone  but  those  of  the  skull.  In  the  College  Museum,  however,  is 
a  well-marked  specimen  in  the  lower  jaw ;  a  nodulated  mass,  nearly 
three  inches  in  diameter,  invests  the  right  angle  of  the  jaw,  and  is,  in 
its  whole  substance,  as  hard  and  heavy  as  ivory.  I  have  already,  also, 
referred  to  cases  of  similar  hard  tumors  on  the  humerus  :  but  they  are 
extremely  rare. 

*  The  histories  of  some  specimens  in  the  Museum  of  St.  George's  Hospital  ilhistrate  these 
statements  very  well.     See,  also,  Mr.  Hawkins's  Lectures  (Med.  Gaz.,  vol.  xxi). 
f  Guy's  Hospital  Reports,  vol.  i. 


OSSEOUS    TUMORS    IN    THE    TOES.  479 

Osseous  tumors  of  the  lower  jaw  appear  to  be  less  rare  in  animals 
inferior  to  man ;  for  the  College  Museum  contains  three  specimens,* 
taken  respectively  from  a  Virginia  opossum,  a  cat,  and  a  kangaroo, 
and,  which  is  more  singular,  one  from  a  codfish.  In  this  specimen, f 
a  disk-shaped  mass  of  bone,  two  inches  in  diameter,  extremely  heavy 
and  compact,  is  attached  to  the  inner  surface  of  the  superior  maxillary 
bone. 

In  the  texture  of  these  very  hard  bony  tumors  connected  with  the 
bones  of  the  skull  and  the  lower  jaw,  we  may  observe  an  instance  of 
the  general  rule  of  likeness  between  tumors  and  the  parts  most  near  to 
them ;  for  their  bone  is  like  no  other  natural  bone  so  much  as  the  in- 
ternal table  of  the  skull,  or  the  petrous  bone,  or  inferior  maxilla. 

The  same  likeness  is  observable  in  the  osseous  tumors  that  are  fre- 
quent on  the  last  phalanx  of  the  great  toe,  which,  alone,  now  remain 
for  me  to  speak  of.| 

No  adequate  explanation,  I  believe,  can  be  offered  for  the  occurrence 
of  these  growths.  They  may  be  sometimes  referred  to  injmy  ;  yet  the 
effects  of  injury  to  the  great  toe  are  so  inconstant,  that  we  cannot  re- 
fer to  injury,  as  other  than  an  indirect  cause  of  the  growth  of  tumors, 
so  singularly  constant  as  these  are  in  all  their  characters,  and  so  nearly 
without  exception  limited  to  the  one  toe  of  all  that  are  exposed  to 
injury.  They  grow  almost  always  on  the  margin,  and  usually  on  the 
inner  margin,  of  the  end  of  the  last  phalanx  of  the  great  toe;  in  only 
one  specimen  have  I  seen  such  a  tumor  springing  from  the  middle  of 
the  dorsal  surface  of  the  phalanx ;  and,  in  only  two,  similar  tumors 
from  the  last  phalanx  of  the  little  toe.§  Growing  up  from  the  margin, 
they  project  under  the  edge  of  the  nail,  lifting' it  up,  and  thinning  the 
skin  that  covers  them,  till  they  present  an  excoriated  surface  at  the 
side  of  the  nail.  Their  growth  is  usually  very  slow,  and  when  they 
have  reached  a  diameter  of  from  one-third  to  one-half  of  an  inch,  they 
commonly  cease  to  grow,  and  become  completely  osseous.  They  are 
among  the  tumors  whose  independence  is  shown  not  only  by  abnormal 
growing,  but  by  the  staying  of  their  growth  when  they  have  attained  a 
certain  natural  stature. 

I  believe  that  they  are  not  uniform  in  their  method  of  development. 
In  some  specimens,  I  have  seen  no  cartilaginous  basis ;  the  bone  ap- 
peared to  form  in  fibrous  tissue,  as  it  were  following,  and  at  length 
overtaking,  the  fibrous  growth.  In  another,  the  outer  part  of  the  tumor 
was  formed  of  a  thin  layer  of  fibrous  tissue,  and  between  this  and  the 

*  Nos.  1036-7-8. 

t  No.  1039.    A  similar  specimen  is  in  the  Museum  of  the  Boston  (U.S.)  Medical  Society. 

X  Mus.  Coll.  Surg.,  787-8-9,  790. 

§  In  the  Anatomical  Museum  of  the  University  of  Edinburgh  are  several  specimens  of 
exostosis  of  the  last  phalanx  of  the  great  toe.  Although  many  of  these  grow  upon  the  inner 
margin,  yet  others  spring  from  the  dorsal  surface,  and  project  under  the  body  of  the  nail. 
In  two  specimens,  the  growth  is  connected  to  the  inner  margin  of  the  base  of  the  last 
phalanx. 


480  OSSEOUS     GKOWTHS    IN    THE     UPPER    JAW. 

growing  bone  was  a  layer  of  cartilage,  which  had  externally  the  stellate 
nuclei,  and  internally  the  nuclei  of  ordinary  form,  among  which  the 
processes  of  bone  were  extending. 

Whichever  way  the  bone  is  formed,  it  is,  like  that  of  the  phalanx 
itself,  cancellous  but  very  hard,  and  with  small  spaces,  and  compara- 
tively thick  cancelli  or  laminae  bounding  them.  The  outer  layer,  too, 
is  rough  and  ill- defined,  so  that  the  growth  looks  like  a  branch  from 
the  phalanx,  and,  like  a  branch,  is  apt  to  sprout  again  when  cut  away, 
unless  at  least  the  end  of  the  bone  on  which  it  grows  be  removed  with  it. 

The  account  of  osseous  tumors  would  be  very  incomplete,  if  there 
were  not  added  to  it  some  notice  of  those  growths  which  are  most  like 
them,  though  they  may  lie  beyond  the  range  of  any  reasonable  or  con- 
venient definition  of  tumors.  Among  these  are  certain  growths  of  the 
bones  of  the  face,  tumor-like  in  their  most  prominent  parts,  and  yet 
unlike  tumors  in  that  their  bases  of  connection  with  the  bones  are  very 
ill-defined,  and  that  from  their  bases  the  morbid  changes  in  which  them- 
selves originated  extend  outwards,  on  the  same  or  even  to  other  bones, 
gradually  subsiding.  In  no  instances  can  it  be  plainer  than  it  is  in 
these,  that  a  nosological  boundary  of  "Tumors"  must  be  an  arbi- 
trary one. 

Such  growths  as  these  are  not  very  rare  in  the  superior  maxillary 
bone.  Its  ascending  process  may  become  enlarged  and  prominent, 
with  an  ill-defined  hard  swelling,  very  slowly  increasing,  and  sometimes 
stopping  short  of  any  considerable  deformity.  But  a  much  more  formi- 
dable disease  exists  when  a  large  portion  of  the  bone,  or  the  whole  an- 
trum, is  involved ;  especially,  because  this  is  apt  to  be  associated  with 
diseases  in  the  adjacent  bones. 

An  extreme  case  is  shown  in  a  specimen  in  the  College  from  the 
Museum  of  Mr.  LangstaiF.*  Two  large  masses  of  bone,  of  almost  ex- 
actly symmetrical  form  and  arrangement,  project  from  the  upper  jaws 
and  orbits,  and  have  partially  coalesced  in  the  median  line.  They  are 
rounded,  deeply  lobed,  and  nodular;  nearly  as  hard  and  heavy  as  ivory; 
perforated  with  numerous  apertures,  apparently  for  bloodvessels.  They 
project  more  than  three  inches  in  front  of  the  face,  and  an  inch  on  each 
side  beyond  the  malar  bones  ;  they  fill  both  orbits,  the  nasal  cavities, 
and  probably  the  antra,  and  they  extend  backwards  to  the  pterygoid 
plates.  Part  of  the  septum  of  the  nose,  and  the  alveolar  border  of  the 
jaw,  are  almost  the  only  remaining  indications  of  a  face.  The  disease 
appears  to  have  begun  in  the  superior  maxillary  bones,  and  thence  to 
have  spread  over  the  bones  of  the  face  :  similar  disease,  in  a  less  degree, 
existing  in  the  bones  adjacent  to  the  chief  outgrowths. 

The  patient,  who  was  sixty  years  old,  believed  the  disease  had  been 
eighteen  years  in  progress,  and  ascribed  it  to  repeated  blows  on  the 

*  Mus.  Coll.  Surg.,  32.36,  A. 


OSSEOUS     GROWTHS    IN    THE     UPPER    JAW.  481 

face.  He  suffered  much  pain  in  the  face,  eyes,  and  head.  His  eyes 
projected  from  the  orbits :  the  right,  after  suppuration  and  sloughing 
of  the  cornea,  shrivelled ;  the  left  was  accidentally  burst  by  a  blow. 
During  the  last  two  years  of  his  life  he  occasionally  showed  symptoms 
of  insanity,  and  at  last  he  died  with  apoplexy  of  the  cerebral  membranes. 

The  disease  very  rarely  attains  so  horrible  a  state  as  is  here  shown. 
More  commonly  it  is  almost  limited  to  the  antrum.  In  this  case  it  may 
exist  with  little  deformity.  In  the  Museum  of  St.  Bartholomew's  Hos- 
pital (i,  62),  is  a  specimen  in  which  both  the  antra  appear  nearly  filled 
by  the  thickening  and  ingrowing  of  their  walls ;  only  small  cavities 
remain  at  their  centres.  The  new  bone  is  hard,  heavy,  and  nearly 
solid  ;  yet  it  is  porous  or  finely  cancellous,  and  is  neither  so  compact 
nor  so  smooth  on  its  cut  surface  as  tha,t  of  the  "  ivory  exostosis."  The 
same  disease  is  manifest  in  a  less  degree  upon  the  outer  surfaces  of  the 
maxillary  bones,  and  on  the  septum  and  side-walls  of  the  nose. 

The  disease  has  a  manifest  tendency  to  concentrate  itself  in  the  max- 
illary bones  ;  so  much  so,  that  if  a  case  be  met  with  where  only  one  of 
these  bones  is  diseased,  it  may  be  removed  with  a  fair  prospect  that 
the  disease  will  not  make  progress  in  the  adjacent  parts.  I  believe, 
indeed,  that  this  has  been  done,  with  a  satisfactory  result,  in  a  case 
where  already  slight  increase  of  some  of  the  bones  near  the  maxillary 
was  observable :  and  there  was  good  reason  to  anticipate  the  same  re- 
sult in  a  case  on  which  Mr.  Stanley  operated.  The  patient  was  a  girl, 
fifteen  years  old,  in  whom  enlargement  of  the  nasal  process  of  the  su- 
perior maxillary  bone  had  been  observed  for  eight  years,  and  was  still 
increasing.  It  had  as  yet  produced  no  pain,  and  no  deformity  of  the 
cheek,  the  orbit,  or  the  palate:  but  it  was  regularly  increasing;  and  as 
it  could  be  certainly  expected  to  increase  even  more  in  width  of  base 
than  in  prominence  (this  being  the  common  tendency  of  the  disease),  it 
was  thought  right  to  remove  the  superior  maxillary  bone  while  yet  the 
disease  was  limited  to  it.  The  patient  died,  ten  days  after  the  opera- 
tion, with  erysipelas.  The  specimen  displays  exactly  the  same  disease 
as  do  those  last  described. 

Now,  it  sometimes  happens  that  growths  like  these  spontaneously 
perish,  are  separated  with  the  ordinary  phenomena  of  necrosis,  and 
thus  are  naturally  cured.  Such  an  event  was  observed  in  a  case  under 
the  care  of  Mr.  Stanley. 

A  man,  37  years  old,  was  admitted  with  a  slight  convex  smooth  pro- 
minence of  the  nasal  process  of  his  right  superior  maxillary  bone,  which 
he  had  observed  increasing  for  two  years,  but  which  of  late  had  not  in- 
creased or  given  him  any  inconvenience.  Indeed,  he  came  to  the  hos- 
pital not  for  this,  but  for  a  swelling  of  the  right  gum  and  the  mucous 
membrane  of  the  hard  palate,  through  fistulous  openings,  in  which  one 
could  feel  exposed  dead  bone.  These  had  existed  for  a  month.  The 
swelling  of  the  nasal  process  was  so  characteristic  of  the  disease  I  am 
describing,  as  to  suggest  at  once  the  existence  of  such  a  growth  ;  but 


482  MULTIPLE    OSSEOUS    GROWTHS. 

the  suppuration  and  necrosis  threw  obscurity  on  the  case  ;  and  it  was 
only  watched  and  treated  according  to  such  indications  as  arose,  till 
after  four  months,  the  whole  of  the  mass  of  bone  with  which  the  antrum 
had  been  filled  up  was  separated  and  pulled  away. 

The  appearance  of  the  sequestrum,  a  nearly  spherical  mass  of  hard, 
heavy,  and  finely  cancellous  bone,  an  inch  or  more  in  diameter,  leaves 
no  doubt  of  the  nature  of  the  disease.*  The  great  cavity  which  re- 
mained, opening  widely  into  both  the  mouth  and  the  nose,  gradually 
contracted,  or  was  filled  up,  and  the  man  recovered  perfectly. 

A  similar  event,  I  imagine,  happened  in  a  man  who  exhibited  himself 
at  most  of  the  hospitals  in  London,  twelve  years  ago,  with  a  great  cavity 
where  all  his  right  upper  jaw-bone  and  his  turbinated  bones  had  once 
been,  and  through  which  one  could  see  the  movements  of  his  pharynx 
and  palate.  This  he  said  had  been  left  after  the  separation  of  a  great 
tumor  of  bone. 

The  growths  of  this  kind  seem  to  merge  gradually  into  elevations  of 
cancellous  porous  bone,  which  may  be  found  on  various  parts  of  the 
bones  of  the  skull,  but  of  the  exact  pathology  and  relations  of  which 
we  have,  I  believe,  no  clear  knowledge.  Specimens  of  them  are  in  the 
Museum  of  the  College,  and  the  Museum  of  St.  Thomas's  Hospital  is 
peculiarly  rich  in  them.  In  some  there  are  great  thickenings  of  one 
or  both  tables  of  the  skull,  raising  up  bosses  of  new  bone  from  half  an 
inch  to  an  inch  in  depth,  on  one  or  both  the  parietal  bones,  or  on  the 
occipital  or  frontal.  In  some,  all  the  bones  of  the  face  are  involved  in 
similar  changes.  In  some,  similar  elevations  are  produced  by  growth 
of  bone  between  the  tables  of  the  skull,  which  themselves  remain  healthy. 
But  as  yet,  I  believe,  we  can  only  look  at  these  as  strange  and  unin- 
structive  things. 

The  last  form  of  bony  growths  that  I  shall  mention  comprises  the  in- 
stances in  which  numerous  exostoses  occur  in  the  same  patient,  and  the 
examples  of  what  has  been  called  the  ossific  diathesis  or  dyscrasia.  In 
the  large  majority  of  cases,  both  cartilaginous  and  osseous  tumors  occur 
singly :  a  few  exceptions  might  be  found  among  such  as  I  have  been 
describing,  yet  the  rule  is  generally  true.  But  in  certain  instances  a 
large  number  of  the  bones  bear  outgrowths  which,  at  least  in  external 
shape,  are  like  tumors.  These  are  commonly  regarded  as  of  constitu- 
tional origin.  Some,  indeed,  appear  to  be  so  in  the  sense  of  consti- 
tutional disease,  which  implies  a  local  manifestation  of  some  morbid 
condition  of  the  blood ;  but  others  can  be  so  called  only  in  that  sense, 
by  which  we  intend  some  original  and  inborn  error  of  the  formative 
tendency  in  certain  tissues  or  organs. 

Of  these  last  we  may  especially  observe  that  the  tendency  to  osseous 
overgrowths  is  often  hereditary,  and  that  its  result  is  a  symmetrical 
deformity.     A  boy,  6  years  old,  was  in  St.  Bartholomew's  Hospital, 

*  The  specimen  is  in  the  Museum  of  St.  Bartholomew's  Hospital. 


DISTINCTIONS     OF    OSSEOUS     GROWTHS.  483 

several  years  ago,  who  had  symmetrical  tumors  on  the  lower  ends  of 
his  radii,  on  his  humeri,  his  scapulae,  his  fifth  and  sixth  ribs,  his  fibulae, 
and  internal  malleoli.  On  each  of  these  bones,  on  each  side,  he  had 
one  tumor ;  and  the  only  deviations  from  symmetry  were  that  he  had 
an  unmatched  tumor  on  the  ulnar  side  of  the  first  phalanx  of  his  right 
fore  finger,  and  that  each  of  the  tumors  on  the  right  side  was  rather 
larger  than  its  fellow  on  the  left. 

I  saw  this  child's  father,  a  healthy  laboring  man,  40  years  old,  who 
had  as  many  or  even  more  tumors  of  the  same  kind  as  his  son's ;  but 
only  a  few  of  them  were  in  the  same  positions.  All  these  tumors  had 
existed  from  his  earliest  childhood ;  they  were  symmetrically  placed, 
and  ceased  to  grow  when  he  attained  his  full  stature  :  since  that  time 
they  had  undergone  no  apparent  change.  None  of  this  man's  direct 
ancestors,  nor  any  other  of  his  children,  had  similar  growths  ;  but  four 
cousins,  one  female  and  three  male  children,  of  his  mother's  sisters,  had 
as  many  of  them  as  himself. 

The  swelling  on  the  little  boy's  fore  finger  was  an  inconvenience  to 
him,  and  at  his  parent's  request  Mr.  Lloyd  removed  the  finger.  The 
swelling  consisted  of  an  outgrowth  or  projection  of  healthy-looking 
cancellous  bone,  full  of  medulla,  and  coated  with  a  thin  layer  of  com- 
pact tissue  ;  its  substance  being  regularly  continuous  with  those  of  the 
phalanx  itself. 

Many  similar  cases  of  symmetrical  and  hereditary  osseous  outgrowths 
might,  I  believe,  be  adduced  ;*  and  all  their  history  suggests  that  they 
are  to  be  regarded  as  related  not  less  closely  to  malformations,  or  mon- 
strosities by  excessive  development,  than  to  the  osseous  tumors  or  out- 
growths of  which  I  have  been  speaking.  Indeed,  at  this  point  the 
pathology  of  tumors  concurs  with  that  of  congenital  excesses  of  deve- 
lopment and  growth.  We  must  distinguish  from  these  cases  the  in- 
stances of  multiple  ossifications  of  tendons,  muscles,  and  other  tissues, 
that  are  occasionally  met  with ;  for  these  only  imperfectly  imitate  the 
forms  of  tumors,  and  are  probably  connected  with  such  a  morbid  con- 
dition of  the  blood  as  really  may  deserve  the  name  of  ossific  dyscrasia 
or  diathesis. 

Before  ending,  it  may  be  proper  to  point  out  the  chief  distinctions 
between  the  osseous  tumors  and  those  growths  which  are  connected  with 
other  tumors  springing  from  the  bones ;  for,  under  the  vague  name  of 
osteo-sarcoma,  many  include  together,  and  seem  to  identify,  all  grawths 
in  which  bone  is  mingled  with  a  softer  tissue. 

The  growths  that  may  chiefly  need  distinction  are  those  of  osteoid 
cancers,  and  the  bony  skeletons  of  certain  medullary  tumors  of  bone. 
Osteoid  cancers  are  probably  examples  of  firm,  or  hard,  or  fibrous  can- 

*  See  Mr.  Stanley's'Treatise  on  Diseases  of  Bones,  p.  152;  and  Mr.  Hawkins's  Lectures 
on  Tumors  of  Bones  (Medical  Gazette,  vol.  xxv,  p.  474).  Also  a  case  reported  in  Med. 
Times  and  Gaz.,  July  9th,  1853,  from  St.  Bartholomew's  Hospital,  by  Mr.  J.  Hutchinson. 


484  GLANDULAR    TUMORS. 

cers,  ossified :  and  the  best  marked  among  tliem  present  an  abundant 
formation  of  peculiarly  hard  bone.  The  distinctions  usually  to  be  ob- 
served between  these  hard  osteoid  cancers  and  the  hard  osseous  tumors 
are  mainly  in  these  particulars:  (a)  the  osteoid  mass,  in  its  mid-sub- 
stance, may  be  compared  with  chalk,  the  osseous  with  ivory ;  the  one  is 
dull  and  powdery,  the  other  bright,  and  wholly  void  of  friability ;  (b) 
the  osteoid  is  new  bone  infiltrated,  as  it  were,  in  some  softer  tissue,  or 
in  the  tissue  of  the  original  bone,  which  disappears  as  it  increases ;  the 
hard  osseous  tumor  is  a  distinct  growth,  attached  in  a  comparatively 
small  part  of  its  extent  to  the  bone  on  which  it  grows ;  (c)  the  outer 
surface  of  an  osteoid  growth  is  porous  and  rough,  and,  if  laminated,  its 
laminae  have  their  edges  directed  outwards ;  while  the  outer  surface  of 
a  hard  osseous  tumor  is  smooth  and  compact,  and,  if  laminated,  the 
surfaces  of  its  laminae  are  directed  outwards;  (d)  lastly,  the  minute 
characters  of  bone  are  far  less  perfect  in  the  osteoid  than  in  the  osseous 
growth:  bone-corpuscles  existing,  indeed,  but  small,  round,  irregular, 
with  very  small,  if  any,  canaliculi,  and  imbedded  in  a  porous,  chalky- 
looking,  basis-substance. 

And,  2dly,  for  distinction  between  the  softer  osseous  skeletons  of 
medullary  cancers,  and  the  cancellous  osseous  tumors,  we  may  chiefly 
observe  that  («)  the  bone  in  cancers  is  more  dry  and  friable  than  the 
cancellous  bone  of  the  osseous  tumors ;  and  (5)  the  bone  in  cancellous 
growths  has  no  medulla,  the  interspaces  between  its  laminge  being  filled 
with  cancerous  matter;  while  medulla  is  a  constant  constituent,  I  believe, 
of  all  the  cancellous  osseous  tumors. 

Such  are  the  chief  differences  generally  to  be  observed  between  the 
bone  of  innocent  and  that  of  malignant  tumors ;  difierences  which  it  is 
well  to  establish,  since  the  fact  is  sufiiciently  confusing,  that  any  nor- 
mal tissue  should  be  formed  in  subordination  to  the  growth  of  cancers. 
The  subject  will  be  again  adverted  to  in  the  lecture  on  Osteoid  Cancer. 


LECTURE    XXVIIL' 

PAKT  1. 
GLANDULAR   TUMORS. 

We  may  call  those  tumors  "  glandular"  which,  in  their  structure, 
imitate  the  glands  ;  whether  the  secreting  glands  or  those  organs  which 
we  name  glands,  because,  though  having  no  open  ducts,  they  are  of 
analogous  structure. 

The  most  frequent  example  of  these  glandular  tumors  is  the  kind 
which  imitates,  and  occurs  in  or  near,  the  mammary  gland ;  the  chronic 


MAMMARY    GLANDULAR     TUMORS.  485 

mammary  tumor  of  Sir  A.  Cooper  ;  the  pancreatic  tumor  of  Mr.  Aber- 
nethy  ;*  the  fibrous  tumor  of  the  breast  of  M.  Cruveilhier.f  Other 
tumors  of  the  same  general  kind  are  more  rarely  found  in  the  lips,  and 
in  or  near  the  prostate  and  the  thyroid  glands.  Probably,  too,  some 
other  tumors,  to  which  no  name,  or  a  wrong  one,  has  been  hitherto  as- 
signed, may  yet  have  to  be  placed  in  this  group  :  indeed,  I  think  it 
nearly  certain  that  there  are  lymphatic  gland-growths,  which  we  usually 
regard  as  enlarged  glands,  but  which  are  really  new  growths,  of  the 
nature  of  tumors,  even  in  the  most  limited  sense  of  the  term.  At  present, 
however,  I  will  have  in  view  only  such  gland-tumors  as  may  be  clearly 
recognized  ;  namely,  such  as  the  mammary  glandular  tumor,  the  labial, 
the  prostatic,  and  the  thyroid. 

Some  of  the  pathology  of  these  tumors  has  been  already  sketched 
in  the  account  of  the  glandular  proliferous  cysts  (pp.  341  and  379).  To 
that  account  I  may  again  refer,  so  far  as  to  the  point  at  which  it  is 
believed  that  an  intra-cystic  growth  has  completely  filled  the  cyst  in 
which  its  growth  began,  and  has  coalesced  with  the  walls,  so  as  to  form 
a  solid  tumor  (p.  380). 

Now,  it  is  perhaps  probable  that  all  glandular  tumors  may  be  formed 
after  this  plan  :  for,  in  those  occurring  in  the  breast,  we  find  sometimes 
one  circumscribed  mass,  composed  half  of  a  proliferous  cyst,  and  half 
of  a  solid  glandular  tumor  ;|  sometimes  two  such  growths  lie  apart,  yet 
in  the  same  gland  (Fig.  49) ;  and  often,  we  find  such  structures  as  we 
doubt  whether  to  call  proliferous  cysts  nearly  filled,  or  mammary  tumors 
(Fig.  5). 

However,  if  all  the  mammary  and  other  glandular  tumors  are  thus 
of  intra-cystic  origin,  it  must  be  admitted  that  many  of  them  very 
early  lose  the  cystic  form,  and  continue  to  grow  as  solid  masses  ;  for 
we  find  them  solid  even  when  they  are  very  small ;  and  they  are  traced 
growing  from  year  to  year,  yet  apparently  maintaining  always  the  same 
texture. 

I  shall  speak  now  of  the  solid  tumors  alone ;  and,  first,  of  the  Mam- 
mary Glandular  Tumors. 

Sir  Astley  Cooper  may  be  said  to  have  had  a  good  insight  into  their 
nature,  when  he  called  them  "chronic  mammary,"  and  said  they  were 
"  as  if  nature  had  formed  an  additional  portion  of  breast,  composed  of 
similar  lobes.  "§  The  analogy  of  their  structure  was  also  recognized 
by  Mr.  Lawrence.  II     But  I  believe  nothing  more  than  this  general  like- 

*  The  mammary  tumor  described  by  Mr.  Abernethy  was  probably  a  medullary  cancer- 
ous disease. 

f  Anatomic  Pathol.,  liv.  xxvi,  pi.  1  ;  and  Bulletin  de  I'Academie  de  Medecine,  t.  ix, 
p.  429. 

$  Mus.  Coll.  Surg.,  177-8.  §  On  Diseases  of  the  Breast,  p.  54. 

II  On  Tumors;  in  Med.-Chir.  Trans.,  vol.  xvii,  p.  29.  It  seems  only  just  to  observe  that 
this  recognition  of  the  obvious  resemblance  between  the  structure  of  these  tumors  and  that 

■  of  the  mammary  gland  vs^as  almost  always  sufficient,  after  the  description  by  Sir  A.  Cooper, 


486  MAMMARY    GLANDULAR    TUMORS. 

ness  had  been  observed,  till  these  tumors  were  examined  with  the 
microscope  by  M.  Lebert,*  who  found  in  them  the  minute  glandular 
structure  imitative  of  the  mammary  gland,  and  recognized  many  of 
their  relations  to  the  proliferous  cysts.  Mr.  Birkett,f  by  independent 
and  contemporary  observations,  made  on  the  great  collection  of  these 
tumors  in  Guy's  Hospital,  confirmed  and  extended  the  conclusions  of 
M.  Lebert,  and  has  cleared  up  much  of  the  obscurity  that  existed  pre- 
vious to  his  inquiries.  Both  these  gentlemen  apply  such  terms  as  "  Im- 
perfect Hypertrophy  of  the  mammary  gland"  to  these  tumors:  but 
highly  as  I  esteem  their  observations  (and  not  the  less,  I  hope,  because 
they  corrected  errors  of  my  own),|  I  would  rather  not  adopt  their  no- 
menclature, since  if  we  do  not  call  these  "tumors,"  I  hardly  know  to 
what  innocent  growths  the  term  could  be  applied.  Nearly  all  innocent 
growths  are  imperfect  hypertrophies,  in  the  same  sense  as  these  growths 
are ;  nay,  these  are,  in  many  respects,  the  very  types  of  the  diseases 
to  which  the  name  of  tumors  is  by  general  consent  ascribed,  and  which 
can  be  distinguished,  even  in  v6rbal  definition,  from  what  are  more  com- 
monly regarded  as  hypertrophies. 

The  mammary  glandular  tumors  may  be  found  in  any  part  of  the 
breast ;  over,  or  beneath,  or  within  the  gland,  or  at  its  border.  Their 
most  rare  seat  is  beneath  the  gland ;  their  most  common  at  its  upper 
and  inner  part,  imbedded  in,  or  just  beneath,  its  surface.  They  are 
usually  loosely  connected  with  the  gland,  except  at  their  deepest  part, 
where  their  capsules  are  generally  fastened  to  it ;  but  the  connection 
permits  them  to  slide  very  easily  under  the  finger,  and  to  be  peculiarly 
movable  in  all  directions. 

The  tumor  is  commonly  of  oval  shape ;  superficially,  or  sometimes 
deeply,  lobed  or  nodular  ;  firm,  or  nearly  hard,  elastic  and  often  feeling 
like  a  cyst  tensely  filled  with  fluid.  The  parts  around  appear  quite 
healthy.  The  mammary  gland  is  pushed  aside ;  but  it  undergoes  no 
other  change  than  that  of  atrophy,  even  when  stretched  over  a  tumor 
of  the  largest  size.  The  skin  under  distension  may  grow  slightly  livid, 
but  else  is  unchanged.  The  veins,  if  the  growth  of  the  tumor  be  rapid, 
may  be  dilated  over  it,  as  over  or  near  a  cancer  of  the  breast.  The 
tumor  is  usually  invested  with  a  complete  capsule,  isolating  it  from  the 
surrounding  mammary  gland,  and  often  adhering  less  to  it  than  to  the 
gland.     This  capsule  may  appear  only  as  a  layer  of  connective  tissue, 

to  enable  the  surgeons  of  this  country  to  avoid  the  confusion  between  the  "  chronic  mammary" 
tumors  and  the  cancers  of  the  breast,  which  M.  Lebert  describes  as  still  prevalent  in  France, 
notwithstanding  his  own  clear  description  of  the  points  of  diagnosis. 

■^  Physiologic  Pathologique,  t.  ii,  p.  201. 

■f"  On  the  Diseases  of  the  Breast,  p.  124. 

J  In  the  Catalogues  of  the  Museums  of  the  College  and  of  St.  Bartholomew's  Hospital 
these  tumors  are  classed  with  the  fibro-cellular.  In  most  of  the  specimens  that  I  had  ex- 
amined the  connective  tissue  was  very  abundant,  and  I  thought  too  lightly  of  the  glandular 
tissue  which  I  found  mingled  with  it.  The  name  adenoid  sarcomata  is  sometimes  applied 
to  these  tumors  of  the  mammary  gland. 


MAMMARY    GLANDULAR    TUMORS.  487 

like  that  around  any  other  innocent  tumor ;  but  it  is  not  unfrequently 
more  perfectly  organized  in  layers,  and  smoother  on  its  inner  surface ; 
conditions  that  we  may  perhaps  ascribe  to  its  having  been  a  perfect  cyst 
within  which  the  glandular  growth  originated,  and  which  the  growth 
has  only  lately  filled. 

On  section,  these  tumors  present  a  lobed  construction,  in  which  it  is 
sometimes  not  difficult  to  discern  the  remains,  or  the  imitation  of  the 
plan,  of  the  lobed,  or  foliated  and  involuted  intra-cystic  growths.  In 
some,  the  connective  tissue  partitions  among  the  lobes  converge  towards 
the  centre  of  the  mass,  as  if  they  were  the  remains  of  clustered  cyst- 
walls  ;  or,  there  may  remain  a  cavity  in  the  centre  of  the  tumor,  as  if 
clustered  cysts  and  growths  had  not  quite  filled  up  the  space.  In  some, 
however,  no  such  plan  is  discernible;  the  whole  mass  is  disorderly 
lobed,  and  its  lobes  have  the  shapes  derived  from  accidental  mutual 
pressure,  and  are  bounded  by  loose  partitions  of  connective  tissue. 

In  structure  as  in  construction,  these  tumors  may  present  several 
variations ;  but  they  may  be  artificially  arranged  in  three  or  four  chief 
groups. 

Some  are  really  very  like  the  normal  mammary  gland  in  an  inactive 
state.  These  have  a  pure  opaque-white,  and  soft,  but  tough  and  elastic 
tissue ;  they  are  lobed,  and  minutely  lobulated,  with  undulating  white 
fibres.  Such  a  one  is  well  shown  in  a  specimen  from  Sir  Astley 
Cooper's  collection,*  in  which,  moreover,  his  injection  of  the  bloodves- 
sels shows  a  moderate  vascularity,  about  equal  to  that  of  the  surround- 
ing normal  gland-substance. 

We  might  take  such  as  this  as  the  examples  of  the  medium  form  of 
this  kind  of  tumor ;  and  the  other  chief  or  extreme  forms  are  repre- 
sented by  those  which  deviate  from  this  in  two  directions.  In  one 
direction  we  find  much  softer  tumors  ;f  these,  though  closely  textured, 
are  soft,  brittle,  or  easily  crushed ;  their  cut  surfaces  shine,  or  look 
vitreous  or  half  translucent ;  they  are  uniformly  grayish- white,  or  have 
a  slight  yellowish  or  pink  hue,  which  deepens  on  exposure  to  the  air ; 
or  they  may  look  like  masses  of  firm,  but  flickering  jelly ;  and  com- 
monly we  can  press  from  them  a  thin  yellowish  fluid,  like  serum  or 
synovia.  Such  as  these  have  the  usual  lobed  and  lobular  plan  of  con- 
struction ;  and  I  think  the  intersecting  partitions  commonly  extend 
from  a  firm,  fibrous-looking  central  or  deep  part,  towards  the  circum- 
ference of  the  tumor. 

In  the  other  direction  from  the  assumed  average  or  medium  form,  we 
find  firmer  tumors.  These  have  a  drier  and  tougher  texture  ;  they  are 
opaque,  milk-white,  or  yellowish,  like  masses  of  dense  connective  tissue, 
lobed,  and  having  their  lobes  easily  separable;  as  in  the  great  specimen, 
weighing  seven  pounds,  in  the  College  Museum  (No.  208). 

*  Mus.  Coll.  Surg.,  No.  2772.  In  this  specimen  there  is  also  a  peculiar  warty  growth  in 
the  skin  over  the  tumor. 

t  Such  as  No.  2774  in  the  College  Museum. 


488 


MAMMARY    QLANDULAR    TUMORS. 


To  such  as  these  varieties  we  might  add  many,  due  not  merely  to 
intermediate  forms,  but  to  the  degrees  in  which  the  intra-cystic  mode  of 
growth  is  manifested ;  or  to  the  development  of  cysts,  which  may  take 
place  as  well  in  this  new  gland-tissue  as  in  the  old ;  or  to  the  various 
contents  of  these  cysts,  whether  liquids  or  organized  growths,* 

I  believe  we  cannot  at  present  always  connect  these  various  aspects 
of  the   tumors   with   any   corresponding    varieties   in    their  histories. 

Neither,  I  think,  have  any  investiga- 
tions proved  more  of  the  corresponding 
varieties  of  microscopic  structure,  than 
that,  as  a  general  rule,  the  tougher  any 
tumor  is,  and  the  slower  its  growth  has 
been,  the  more  it  has  of  the  connective, 
mingled  with  its  glandular,  tissue ;  while 
the  more  succulent  and  vitreous  one  is, 
and  the  more  rapid  its  growth,  the  less 
perfectly  is  the  glandular  tissue  developed. 
The  microscopic  structures  may  be 
best  described  from  a  medium  specimen  : 
from  such  a  one  I  made  these  illustra- 
tive sketches.  The  patient  was  33  years 
old  ;  the  tumor  had  been  noticed  seven 
^         _..  months,  and  was  ascribed  to  a  blow  ;  it 

^^  was  painful  at  times,  and  increasing  ;  and 

it  had  the  several  characters  that  I  have 
already  described.     The  patient  has  remained  well  since  its  removal. 

In  such  a  tumor  one  finds,  in  thin  sections,  traces  of  a  minute  lobular 
or  acinous  form ;  the  miniature,  we  might  say,  of  that  which  we  see 
with  the  naked  eye.  The  lobules  may  be  merely  placed  side  by  side, 
with  little  or  no  intervening  tissue ;  their  form  may  appear  to  depend 
on  the  arrangement  of  their  contents,  and  these  may  seem  scarcely 
bounded  by  membrane.  But,  I  think,  more  commonly,  especially  in 
the  firmer  specimens,  the  plan  of  lobules  or  acini  is  mapped  out  by  par- 
titions of  filamentous-looking  tissue,  fasciculi  of  which,  curving  and 
variously  combined,  appear  to  arch  over,  and  to  bound,  each  acinus  or 
lobule.  But  great  varieties  appear  in  the  quantity  of  this  tissue  ;  it 
may  be  nearly  absent,  or  it  may  so  predominate  as  to  obscure  the  traces 
of  the  essential  glandular  structure. 

This  proper  gland-structure  consists  of  minute  nucleated  cells  and 
nuclei,  clustered  in  the  lobular  form,  or  in  that  of  cylinders  or  tubes. 


%®  e 


*  I  believe  these  include  the  chief  examples  of  Miiller"s  Cysto-sarcomata.  One  of  these 
tumors  containing  simple  cysts  would  constitute  his  cysto-sarcoma  simplex:  the  cysts  being 
proliferous  with  gland  growths  would  make  his  cysto-sarcoma  phyllodes. 

f  Fig.  75.  Minute  structures  of  a  mammary  glandular  tumor,  described  in  the  text :  mag- 
nified 350  times.  The  microscopic  examinations  of  several  specimens  may  be  found  in 
Lebert  (Phys.  Pathol.,  ii,  190;  and  Abhandlungen,  p.  269)  ;  Birkett,  On  Diseases  of  the 
Breast,  pi.  2,  3,  4,  &c. ;  and  Bennett,  On  Cancerous  and  Cancroid  Growths,  p.  52. 


MAMMARY    GLANDULAR    TUMORS.  489 

and  often,  or  perhaps  always  in  their  most  natural  state,  invested  with 
a  simple,  pellucid,  limitary  membrane. 

Thus,  the  likeness  is  striking  between  the  structure  of  such  a  tumor, 
and  that  of  an  inactive  mammary  gland,  such  as  that  of  a  male,  as  Mr. 
Birkett  has  pointed  out.  We  have  here  what  may  be  compared  with 
the  round  or  oval  csecal  terminations  of  the  gland-tubes  clustered  to- 
gether, and  often  seeming  grouped  about  one  trunk-tube  ;  and  in  these 
we  have  the  simple  membrane  and  the  gland-cells  and  nuclei  within ; 
only  the  main  duct  is  wanting,  and  the  communication  with  the  ducts 
of  the  proper  gland.  It  is  as  if  the  proper  secreting  structure  of  a 
gland  were  formed  without  connection  with  an  excretory  tube  ;  the 
tumor  is,  in  this  respect,  like  one  of  the  glands  without  ducts.* 

The  mammary  glandular  tumors  are  singularly  variable  in  all  the 
particulars  of  their  life.  They  sometimes  grow  quickly ;  as  did  the 
largest  figured  by  Sir  A.  Cooper,  which,  in  two  years,  acquired  a  weight 
of  a  pound  and  a  half.  In  other  cases  their  growth  is  very  slow  ;  I 
have  known  onef  which,  in  four  years,  had  not  become  so  much  as  an 
inch  in  diameter.  In  some  instances  they  remain  quite  stationary,  even 
for  many  years.  One|  was  removed  from  a  woman  27  years  old :  it 
was  observed  for  14  years,  and  in  all  that  time  it  scarcely  enlarged ; 
yet  after  this  it  grew  so  rapidly,  that,  in  six  months,  it  was  thought 
imprudent  to  delay  the  removal.  Cases  of  this  arrest  or  extreme  re- 
tardation of  growth  must  have  been  seen  by  most  surgeons  ;  but  there 
are  few  cases  so  striking  as  one  related  by  M.  Cruveilhier,  in  which  a 
lady  had,  for  more  than  twenty  years,  three  of  these  tumors  in  one 
breast,  and  one  in  the  other.  She  died  in  consequence  of  the  treatment 
employed  against  them,  and  after  death  no  similar  disease  was  found  in 
any  other  part. 

Equal  variations  exist  in  regard  to  pain.  Commonly  these  tumors 
are  painless ;  but  sometimes  they  are  the  seats  and  sources  of  intense 
suffering ;  even  of  all  that  suffering  which  is  popularly  ascribed  to 
cancer,  but  which  cancer  in  its  early  stages  so  very  rarely  presents. 
The  irritable  tumor  of  the  breast,  as  Sir  A.  Cooper  named  it,  was  in 
most  of  his  cases  a  mammary  glandular  tumor  ;§  and  the  character  of 
the  pain,  like  that  of  the  painful  subcutaneous  tumor  (p.  419),  is  such 
as  we  may  name  neuralgic. 

A  tumor,  II  evidently  glandular,  was  taken  from  the  breast  of  a  woman 
twenty-five  years  old,  where  it  had  been  growing  for  two  years  ;  it  had 

*  In  one  of  these  tumors,  removed  from  abreast  in  which  lactation  was  going  on,  Billroth 
noticed  that  milk  was  secreted  by  the  gland-like  lobules  of  the  tumor. — Virchow"s  Arcliiv, 
1859,  vol.  xviii. 

f  Museum  of  St.  Bartholomew,  Ser.  xxxiv.  No.  23. 

X  Mus.  Coll.  Surg.,  207  B. 

§  Under  the  same  name,  however,  he  included  some  that  were  more  probably  "  Painful 
subcutaneous  Tubercles :''  see  his  pi.  viii,  figs.  2,  4,  5,  7. 

II  Mus.  St.  Bartholomew's  Hospital,  Ser.  xxxiv,  No.  22. 

32 


490  MAMMARY    GLANDULAR    TUMORS. 

often  been  the  seat  of  the  most  intense  pain.  I  referred  to  a  similar 
case  while  speaking  of  neuralgic  tumors  (p.  420),  and  I  removed  a  simi- 
lar tumor  from  the  breast  of  a  young  lady,  who  begged  for  its  removal 
only  that  she  might  be  relieved  from  severe  suffering.  In  all  these 
cases  the  minute  glandular  structure  was  well  marked. 

A  peculiarity  of  these  tumors  is,  that  they  not  unfrequently  disap- 
pear ;  an  event  very  rarely  paralleled  in  any  other  tumor.  They  are 
most  likely  to  do  this  in  cases  in  which  any  imperfection  of  the  uterine 
or  ovarian  functions,  in  which  they  may  have  seemed  to  have  their  ori- 
gin, is  repaired  by  marriage,  or  pregnancy,  or  lactation.  And  the 
fact  is  very  suggestive :  since,  in  many  cases,  it  appears  as  if  the  discon- 
tinuous hypertrophy,  which  constitutes  the  tumor,  were  remedied  by 
the  supervention  of  a  continuous  hypertrophy  for  the  discharge  of  in- 
creased functions  of  the  gland. 

On  the  other  side,  these  tumors  often  continue  to  grow  indefinitely, 
and  they  may  thus  attain  an  enormous  size.  One  was  removed  by  Mr. 
Stanley,  which,  after  twelve  years'  progress,  in  a  middle-aged  woman, 
measured  nearly  twelve  inches  in  length,  and  weighed  seven  pounds. 
It  was  pendulous ;  and,  as  she  sat,  she  used  to  rest  it  on  her  knee,  till 
the  integuments  began  to  slough.  Mr.  Stanley  merely  sliced  it  off, 
cutting  through  the  pedicle  of  skin  ;  and  the  patient  remained  well  for 
at  least  seven  years.  The  tumor  was  one  of  the  firmest  and  most  fila- 
mentous of  the  kind.* 

In  the  College  Museum  is  a  tumorf  of  the  same  kind,  but  softer  and 
much  more  succulent,  which  was  removed  by  Mr.  Liston  from  a  woman 
forty-four  years  old,  and  which  weighed  twelve  pounds. 

Respecting  the  origin  of  these  tumors,  little  more,  I  believe,  can  be 
said  than  that,  occurring  most  commonly  in  young  unmarried  or  barren 
women,  their  beginning  often  seems  connected  with  defective  or  disor- 
dered menstruation.  The  law  which,  if  we  may  so  speak,  binds  to- 
gether in  sympathy  of  nutrition  the  ovaries  and  the  mammary  glands, 
the  law  according  to  which  they  concur  in  their  development  and  ac- 
tion, is  not  broken  by  one  with  impunity  to  the  other.  The  imperfect 
office  of  the  ovary  is  apt  to  be  associated  with  erroneous  nutrition  in 
the  mammary  gland. 

I  have  seen  only  one  specimen  of  the  mammary  glandular  tumor  in 
a  male.  A  portion  of  it  was  sent  to  me  by  Mr.  Sympson,  and  its  charac- 
ters were  well  marked.  It  was  removed  by  Mr.  Hadwen,  from  a  coun- 
tryman, twenty-five  years  old,  in  whom  it  had  been  growing  regularly, 
and  occasionally  diminishing  or  disappearing,  for  about  five  years. 
When  removed,  it  formed  a  circular,  flattened,  and  slightly  lobulated 
tumor,  3^  inches  in  diameter,  and  an  inch  in  thickness,  invested  with  a 
distinct  connective-tissue  capsule,  which  loosely  connected  it  to  the  adja- 
cent tissues. 

*  Mus.  Coll.  Surg.,  No.  208.  f  Mus.  Coll,  Surg.,  No.  216, 


MAMMARY    GLANDULAR    TUMORS.  491 

There  are,  I  believe,  no  facts  to  suggest  that  the  glandular  tumors 
are,  as  a  rule,  other  than  innocent.  More  than  one  may  grow  in  a 
breast  at  the  same  or  several  successive  times ;  but  I  have  not  known 
of  more  than  three  either  at  once  or  in  succession.  Neither  am  I  aware 
of  any  facts  which  prove  what  is  commonly  believed,  that,  after  a  time, 
these  tumors  may  become  cancerous.  Such  things  may  happen  ;  and, 
on  the  whole,  one  might  expect,  that  if  a  woman  have  a  tumor  of  this 
kind  in  her  breast,  cancer  would  be  more  apt  to  affect  it  as  a  morbid 
piece  of  gland,  than  to  aifect  the  healthy  gland.  But,  I  repeat,  I  know 
no  facts  to  support  this  ;  and  some  that  I  have  met  with  are  against  it. 
Thus,  in  the  Museum  of  St.  Bartholomew's,  is  a  portion  of  breast,* 
from  a  woman  thirty-two  years  old,  in  which  there  lie,  far  apart,  a 
small  mammary  glandular  tumor  that  had  existed  four  years,  and  a  hard 
cancer  that  had  existed  four  months.  A  second  specimenf  shows  a 
hard  cancer  and  a  proliferous  cyst,  in  the  breast  of  a  patient,  who  died 
some  time  after  its  removal,  with  recurrence  of  the  cancer  ;  and  I  be- 
lieve that  they  are  not  counterbalanced  by  any  of  an  opposite  kind. 

And  yet,  while  all  the  characters  of  innocent  tumors  are  generally, 
if  not  always,  observed  in  these,  there  are  facts  concerning  a  seeming 
connection  between  mammary  glandular  tumors  and  cancer  which  must 
not  be  passed  by  here  ;  though  they  may  need  to  be  again  stated  in  the 
last  lectures  on  cancer. 

It  has  sometimes  happened  that  a  glandular  tumor  has  been  removed 
from  a  breast,  and,  within  a  short  time,  the  same  breast  has  become  the 
seat  of  cancer.J  I  believe  that  the  explanation  of  such  cases  as  these 
may  be,  that  a  woman,  prone  to  cancer  by  some  constitutional  condi- 
tion, or,  especially,  by  hereditary  disposition,  had  (as  any  other  might) 
a  glandular  tumor  in  her  breast ;  and  that  the  operation  for  removing 
this  tumor  inflicted  a  local  injury,  and  made  the  breast  apt  to  be  the 
seat  of  cancer,  of  which  already  (as  one  may  say)  the  germ  existed  in 
the  blood.  Such  events  may  prove  only  an  accidental  connection  be- 
tween the  glandular  tumors  and  the  cancer  ;  but  they  are  enough  to 
suggest  great  caution  in  operating  on  the  breasts  of  those  who  may  be 
suspected  to  be,  by  inheritance,  peculiarly  liable  to  cancer. 

But,  again,  cases  sometimes  occur  in  which,  I  think,  the  mammary 
glandular  tumors  supply  examples  of  what  I  have  already  suggested  as, 
probably,  a  general  truth :  namely,  that  the  children  of  a  cancerous 
parent,  or  those  in  whose  family  cancer  is  prone  to  occur,  are  apt  to 
have  tumors  which  may  be  like  innocent  tumors  in  their  structure,  but 
may  resemble  cancers  in  a  peculiar  rapidity  of  growth,  and  a  proneness 
to  ulceration  and  recurrence  after  removal.  A  striking  instance  of  this 
occurred  in  Mr.  Lawrence's  practice.  He  removed  the  breast  of  a  lady, 
from  one  of  whose  sisters  Mr.  Aston  Key  had  removed  a  breast  said  to 

*  Ser.  xxxiv,  No.  17.  f  Mus.  St.  Bartholomew's  Hospital,  Ser.  xxxiv,  No.  16. 

J  See  such  a  case,  by  Mr.  Eriehsen,  in  the  Lancet,  Feb.  14,  1852  ;  and  the  history  of  a 
series  of  preparations  in  the  Catalogue  of  the  Museum  of  St.  Bartholomew's,  vol.  i,  p.  446. 


492  LABIAL    GLANDULAR    TUMORS. 

be  affected  with  "fungoid"  disease,  whose  mother  had  died  with  well- 
marked  hard  cancer  of  the  breast,  and  in  other  members  of  whose  family 
cases  of  cancer  were  believed  to  have  occurred.  The  breast  removed 
by  Mr.  Lawrence  comprised  a  huge  sloughing  and  ulcerating  mass  of 
yellowish,  soft,  flickering  substance,  like  the  softest  of  these  mammary 
glandular  tumors,  or  like  the  very  soft  pellucid  growths  which  I  have 
described  as  occurring  in  some  of  the  proliferous  cysts  of  the  breast. 
The  diseased  state  of  the  mass  (in  consequence  of  escharotics  having 
been  recklessly  used)  was  such,  that  minute  examination  showed  little 
more  than  the  absence  of  distinct  cancer-structures.  During  the  heal- 
ing of  the  wound,  and  for  some  months  after  it,  fresh  growths  re- 
peatedly appeared.  Some  of  these  which  I  have  examined  were  yellow, 
pellucid,  soft,  viscid,  almost  like  lumps  of  mucus,  or  of  half-melted  gela- 
tine, imbedded  in  the  tissues  of  the  integuments  or  scar.  With  the 
microscope  I  found  only  granules  and  granule-masses,  with  elongated 
nuclei,  themselves  also  granular,  set  in  abundant  pellucid  substance.  I 
found  no  sign  of  cancer-structure  or  of  gland-structure.  The  substance 
resembled  that  which  I  have  mentioned  (p.  383)  as  found  in  some  of  the 
imperfect  proliferous  mammary  cysts. 

Now,  after  repeated  removals  of  such  growths  as  these,  the  Avounds 
completely  healed,  and  the  patient  has  remained  well,  and  in  good  gene- 
ral health,  for  eighteen  months. 

At  nearly  the  same  time,  a  third  sister  of  this  family  was  under  Mr. 
Lawrence's  care,  and  he  removed  one  of  her  breasts  in  which  was  a  great 
mass,  which  had  grown  quickly,  and  was  chiefly  composed  of  well- 
marked  glandular  tissue,  either  in  separate  solid  growths,  or  inclosed  in 
proliferous  cysts.  But  some  parts  also  of  this  tumor  were  soft,  pellucid, 
and  gelatinous ;  and  others  were  as  soft,  but  opaque  and  dimly  yellow. 
In  the  firmer  parts,  the  glandular  texture  was  as  distinct  with  the  mi- 
croscope as  with  the  naked  eye  :  in  the  softer  parts  no  such  structures 
were  seen,  but  abundant  free  cells  and  nuclei,  of  most  various  and 
apparently  disorderly  shapes ;  some  elongated,  like  small  shrivelled 
fibro-cells ;  some  flattened,  like  small  epithelial  cells.  I  would  not  ven- 
ture on  an  opinion  of  what  these  were  or  indicated ;  I  think  they  were 
not  cancerous,  and  the  disease  has  not  returned.  The  main  fact  of  all 
the  cases  is,  that  three  daughters  of  a  cancerous  mother  had  mammary 
tumors ;  in  two,  at  least,  of  them  the  structure  was  probably  not  can- 
cerous ;  and  yet  the  rapid  growth,  the  recurrences  in  one  of  them,  and 
the  defective  or  disordered  modes  of  growth  in  both,  were  such  as  marked 
a  wide  deviation  from  the  common  rules  of  mammary  glandular  or  any 
other  innocent  tumors,  and  a  deviation  in  the  direction  towards  cancer. 

Labial  glandular  tumors  may  be  briefly  described,  for  their  gene- 
ral characters  correspond  closely  with  those  of  the  foregoing  kind ;  or, 
they  may  appear  intermediate  in  character  between  the  foregoing  and 
those  tumors  which  I  described  as  lying  over  or  near  the  parotid  gland, 


LABIAL    GLANDULAR    TUMORS. 


493 


Fig.  76.t 


and  as  consisting  of  mixed  glandular  and  cartilaginous  tissue.  Their 
likeness  to  these  tumors  over  the  parotid  was  manifest  to  Mr.  Lawrence, 
who  has  added  to  his  account  of  the  tumors  by  the  parotid,  the  only 
case  of  labial  glandular  tumor  that  I  have  found  on  record.* 

The  most  marked  case  of  labial  glandular  tumor  that  I  have  seen  was 
that  of  a  healthy-looking  man,  some  years  ago,  under  the  care  of  Mr. 
Lloyd.  A  tumor  had  been  growing  in  his  upper  lip  for  twelve  years. 
It  was  not  painful,  but  the  protrusion  of  the  lip  was  inconvenient  and 
ugly,  the  swelling  being  an  inch  in  diameter.  It  was  imbedded  in  the 
very  substance  of  the  lip,  both  the  skin  and  mucous  membrane  being 
tensely  stretched  over  it.  Its  form  was  nearly  hemispherical,  its  pos- 
terior surface  being  flattened  as  it  lay  close  on  the  gums  and  teeth,  its 
anterior  convex  and  smooth.  Its  whole  substance  was  firm,  tense,  and 
elastic. 

Mr.  Lloyd  removed  the  tumor  with  the  mucous  membrane  over  it, 
leaving  the  skin  entire.  The  tumor  was  firm,  slightly  lobed,  yellowish- 
white,  smooth.  In  general  aspect  it  resembled  the  mixed  tumors  over 
the  parotid,  but  in  minute  structure 
it  presented  as  perfect  an  imitation 
of  lobulated  or  acinous  gland-struc- 
ture as  any  mammary  glandular  tu- 
mor. Its  tubes  and  their  dilated  ends 
had  distinct  limitary  membrane,  and 
were  filled  with  nuclei  and  nucleated 
cells,  like  those  of  the  labial  glands 
(Fig.  76).  I  heard  some  months  after- 
wards that  another  tumor  was  grow- 
ing in  the  same  lip ;  but  the  patient 
was  lost  sight  of.  Such  a  recurrence, 
even  if  it  really  happened,  would  be 
no  sufiicient  evidence  of  malignancy. 

I  removed  a  similar  tumor  from  the 
upper  lip  of  a  man  about  30  years 
old.  It  had  been  regularly  growing 
for  four  years  without  pain,  and  pro- 
jected far  externally,  reaching  to  the 
same  distance  as  the  end  of  his  nose. 
This  had  a  texture  of  glandular  kind, 
but  less  distinctly  marked  than  that 
in  the  former  case.  Moreover,  in  the 
centre  of  the  mass  was  a  portion  of 


@    0  %  §© 


*  Medico-Chirurgical  Transactions,  vol.  xvii,  p.  28. 

f  Fig.  76.  A,  structure  like  the  esecal  terminations  of  gland-ducts  in  an  acinus;  b,  a  sepa- 
rate portion  of  gland-like  tube ;  C,  separate  gland-cells,  and  free  nuclei ;  from  the  labial 
glandular  tumor  described  in  the  text.  A  and  B  magnified  300  times;  C  magnified  400 
times. 


494         PROSTATIC    AND    THYROID    GLANDULAR    TUMORS. 

bone;  a  peculiarity  whicli  existed  also  in  Mr.  Lawrence's  case,  and 
which  may  add  to  the  probability  of  relationship  between  these  tumors 
and  the  mixed  glandular  and  cartilaginous  tumors  over  the  parotid. 

Lastly,  I  may  again  refer  to  a  specimen  in  the  Museum  of  St. 
George's  Hospital,  in  which,  in  one  tumor,  a  cyst  and  what  looks  like 
one  of  these  glandular  growths  are  combined  (see  p.  384).* 

Prostatic  glandular  tumors  were  briefly  referred  to  in  the  first 
lecture  on  tumors  (p.  342),  as  examples  of  the  abnormal  growths  by 
which  tumors  appear  to  be  connected  with  simple  hypertrophies  of 
organs ;  and  I  can  add  little  to  what  was  then  said  of  them. 

We  owe  to  Rokitanskyf  the  knowledge  that  the  tumors  in  the  pro- 
state gland,  which  were  commonly,  and  till  lately  even  by  himself,  re- 
garded as  fibrous  tumors,  are  composed  of  tissues  like  those  of  the  pro- 
state gland  itself.  In  enlarged  prostates  they  are  not  unfrequently  found. 
In  cutting  through  the  gland,  one  may  see,  amidst  its  generally  lobed 
structure,  portions  which  are  irivested  and  isolated  by  connective  tissue, 
and  may  be  enucleated.  Such  portions  have,  I  believe,  been  sometimes 
removed  as  tumors,  or  as  portions  of  prostate  gland,  in  operations  of 
lithotomy.  They  lie  imbedded  in  the  enlarged  prostate,  as,  sometimes, 
mammary  glandular  tumors  lie  isolated  in  a  generally  enlarged  breast. 
They  look  like  the  less  fasciculate  of  the  fibrous  tumors  of  the  uterus ; 
but,  to  microscopic  examination,  they  present  such  an  imitation  of  the 
proper  structure  of  the  prostate  itself,  that  we  cannot  distinguish  the 
gland-cells  or  the  smooth  muscular  fibres  of  the  tumor  from  those  of  the 
adjacent  portions  of  the  gland.  Only  their  several  modes  of  arrange- 
ment may  be  distinctive. 

At  present  the  examinations  of  these  tumors  have  been  too  few  to 
furnish  a  complete  history  of  them :  neither  can  I  add  any  cases  or 
references  to  those  which  were  adduced  in  the  first  lecture. 

The  thyroid  glandular  tumors  were  similarly  referred  to  in  the 
same  lecture.  Their  history  is  merged  in  that  of  bronchoceles,  with 
which  they  are  usually  associated,  whether  imbedded  as  distinct  masses 
in  the  enlarged  gland,  or  lying  close  by  it,  but  discontinuous.  Yet  I 
suspect  that  similar  growths,  of  substance  like  thyroid  gland,  may 
occur,  as  tumors,  further  from  the  normal  mass  of  the  gland. 

Mr.  Stanley  removed  a  tumor  from  the  neck  of  a  woman  62  years 
old.  It  had  been  observed  for  fifty  years  ;  for  the  first  thirty  of  which 
it  was  like  a  little  loose  "kernel"  under  the  skin,  and  scarcely  in- 
creased. In  the  next  ten  years  it  grew  more  quickly,  and  in  the  next 
ten  more  quickly  still ;  and  now,  the  skin  over  it  ulcerated,  and  it  pro- 

*  Billroth  relates  a  case  in  which  one  of  these  tumors  grew  in  connection  with  the  mu- 
cous membrane  of  the  cheek,  about  one  inch  from  the  angle  of  the  mouth.  It  was  removed, 
and  twice  recurred  after  the  first  extirpation.     Virchow's  Archiv,  vol.  xvii,  p.  374. 

j-  Ueber  die  Cyste,  1849  j  and,  Anatomie  des  Kropfes. 


ERECTILE    OR    VASCULAR    TUMORS.  495 

truded  and  occasionally  bled,  but  was  never  painful.  It  looked  like  an 
ulcerated  sebaceous  cyst,  seated  upon  a  subcutaneous  tissue  at  the  lower 
part  of  the  neck,  just  in  front  of  the  trapezius.  No  cause  could  be 
assigned  for  it. 

On  section  it  appeared  as  a  solid  tumor  with  a  thin  connective-tissue 
capsule,  partitions  entering  from  which  divided  it  into  distinct  round 
lobes.  Its  proper  substance  was  soft,  elastic,  glistening,  yellowish, 
blotched  and  streaked  with  brownish  pink  and  blood  colors.  It  was,  to 
the  naked  eye,  like  a  piece  of  bronchocele,  with  such  an  arrangement 
of  its  parts  as  would  exist  when  numerous  cysts  are  filled  with  the 
glandular  growth,  and  compacted.  And  the  general  impression  hence 
derived  was  confirmed  by  microscopic  examination,  which  showed  that 
the  tumor  consisted,  chiefly,  of  round  and  oval  bodies,  or  minute  sacculi, 
from  Y^gth  to  5^0*^  of  an  inch  in  diameter,  filled  or  lined  with  nucle- 
ated substance,  or  with  nuclei  imbedded  in  a  dimly  molecular  blastema, 
and  not  nucleolated.  These  bodies  were  closely  apposed,  but  frequently 
appeared  separated  by  thin  filaments,  or  connective-tissue  partitions. 
The  nuclei  were  very  uniform,  circular,  about  4o\)otli  of  an  inch  in  dia- 
meter, and  in  general  aspect  like  the  nuclei  of  vascular  glands  or 
lymph  glands.  Numerous  similar  nuclei  appeared  free ;  and  some  ap- 
peared imbedded  in  a  dimly  molecular  blastema  which  was  not  inclosed 
in  cysts  or  sacculi,  nor  divided  by  partitions  of  connective  tissue. 

I  have  seen  no  other  tumor  like  this ;  nor  any  natural  texture  that 
it  resembled  except  the  thyroid  gland.  Future  observations  must 
prove  whether  thyroid  glandular  tumors  can  be  formed  so  far  from 
the  normal  gland,  with  the  cervical  fascia,  great  bloodvessels  of  the 
neck,  and  other  adjacent  parts,  intervening  between  them. 


LECTURE   XXVIII. 

PAKT  II. 

ERECTILE    OR    VASCULAR    TUMORS. 

The  ERECTILE  OR  VASCULAR  TUMORS  include  most  of  the  diseases 
which  are  described  as  vascular  nsevi,  and  of  which  the  types  are  the 
subcutaneous  nsevi.  Among  them,  also,  are  the  growths  to  which  John 
Bell  gave  the  name  of  aneurism  by  anastomosis,  and  those  which  have 
been  called  Telangeiectasis. 

The  name  "  erectile  tumor"  has,  of  late  years,  come  into  general  use, 
as  expressing  a  principal  fact  concerning  these  diseases, — namely,  that 
many  of  them  resemble  very  closely  in  their  texture  that  of  erectile  or 
cavernous  tissue.     Dr.  Humphry*  has,  indeed,  righly  objected  to  the 

*  Lectures  on  Surgery,  p.  111. 


496 


ERECTILE  OR  VASCULAR  TUMORS. 


use  of  the  term,  that  these  tumors  present  no  imitation  of  the  erectile 
tissue  in  the  power  of  filling  themselves  with  blood,  as  if  by  some  inter- 
nal force.  But,  since  this  occurrence  in  the  true  erectile  tissue  depends 
as  much  on  the  accessory  structures  of  nerves  and  muscles  as  on  the 
tissue  itself,  we  may  fairly  apply  the  term  "erectile"  to  the  tumors, 
remembering  only  for  this,  as  for  other  structures  occurring  in  tumors, 
that  the  imitation  of  the  natural  tissue  is  imperfect,  or  partial.  How- 
ever, if  any  be  scrupulous  in  the  use  of  these  terms,  they  may  call  these 
tumors  vascular,  or  cavernous,  or  even  Telangeiectasis. 

The  likeness  which  these  tumors  bear  to  the  erectile  tissue,  as  exem- 
plified in  the  corpus  cavernosum  penis,  is  sometimes,  in  general  appear- 
ance, perfect.  A  well-marked  specimen  is  in  the  Hunterian  collection,* 
from  which  the  adjoining  sketch  was  made  (Fig.  77).  It  was  removed 
from  under  the  lower  jaw,  and  its  cut  surface  displays  a  close  network 
or  sponge  of  fine,  smooth,  shining  bands  and  cords,  just  like  those  of 
the  corpus  cavernosum  penis,  only  less  regular  in  their  arrangement. 
The  opportunities  of  examining  such  tumors  in  the  recent  state  are 
very  rare ;  and  they  are  usually  spoiled  by  the  operations  for  removing 
them ;  but  what  I  have  seen,  and  the  descriptions  which  others  have 
recorded,  leave  little  doubt  that  this  imitation  of  erectile  tissue  is  a  fre- 
quent character  among  them. 

John  Bell's  accountf  of  the  aneurism  by  anastomosis,  which  is  by 

far  the  most  vivid  and  exact,  in  re- 
lation to  the  history  of  the  disease, 
that  has  yet  been  published,  accords 
..  - with  this  statement.     Although  he 

/i'iMfmilS'l^^^SlS^?^^  ^^^   chiefly   in    view    the    arterial 

-.  B«tllBml^l«Jli^MiHfAiA%  variety  of  these  tumors,  yet  of  one 

he  says,  "  The  substance  of  it  was 
cellular,  stringy,  and  exactly  re- 
sembling the  corpora  cavernosa 
penis  .  .  .  the  cells  were  filled  with 
blood  from  the  arteries,  which  en- 
tered the  tumor  in  all  directions." 
Another  he  compares  to  a  sponge 
soaked  in  blood ;  and  the  descrip- 
tions of  other  examples,  though  less 
explicit,  imply  the  same.  The  de- 
scriptions by  Mr.  'Wardrop§  and 
Mr.  Caesar  Hawkins, ||  and  the  more 
minute    accounts  of    structure    by 


Fig.  77.t 


*  Mus.  Coll.  Surg.,  301  a.  f  Principles  of  Surgery,  vol.  i,  p.  456,  e.  s. 

J  Fig.  77.  Section  of  an  erectile  tumor  in  the  College  Museum,  described  above.     It  is 
dravi^n  one-third  larger,  and  rather  coarser,  than  naturaL 
§   Med.-Chir.  Trans.,  vol.  ix,  p.  201,  and  pi.  vi. 
II  Medical  Gazette,  vol.  xxxvii,  p.  1027. 


ERECTILE    OR    VASCULAR    TUMORS.  497 

Mr.  Goodsir,*  and  Mr.  Listonf  and  Rokitansky,|  confirm  this  view  ; 
and  neither  Mr.  Birkett's,§  nor  any  other  that  I  have  met  with,  is  dis- 
cordant from  it. 

The  essential  structures  of  the  disease  are,  according  to  these  de- 
scriptions, derived  from  such  a  growth  of  bloodvessels,  or  rather  of 
blood-spaces,  that,  in  imitation  of  erectile  tissue,  the  whole  mass  seems 
formed  of  cells  or  spaces,  opening  widely  into  one  another  :  and,  in  ex- 
treme cases,  no  remains  exist  of  the  walls  of  the  vessels,  except  those 
narrow  bands  and  cords  that  bound  and  intersect  the  cell-like  spaces. || 

The  division,  often  made,  of  erectile  or  vascular  tumors  into  such  as 
are  named,  respectively,  "  arterial,"  "  capillary,"  and  "venous,"  is  con- 
venient, and  probably  well-founded.  The  most  frequent  examples  of 
subcutaneous  nsevi,  and  the  more  frequent  superficial  nsev'i,  which  are 
like  them  in  structure,  though  different  in  position,  appear  to  consist, 
mainly,  of  closely  arranged  minute  bloodvessels,  of  which  some  are  as 
small  and  as  simple  as  medium-sized  capillaries,  while  others,  of  various 
size,  appear  as  dilated  capillaries,  or  as  small  arteries  and  veins  densely 
clustered,  but  in  just  proportions  to  one  another.  These  are  such  as 
may  be  called  "  capillary  ;"  understanding,  only,  that  they  probably 
afi"ect  minute  arteries  and  veins  as  well  as  capillaries.  But,  on  the  one 
hand,  deviating  from  these  specimens,  we  find  that  in  some  cases  the 
enlargement  of  arteries  far  exceeds,  in  proportion,  that  of  the  veins ; 
the  swellings  pulsate,  and  are  florid  and  over-warm,  and,  if  injured, 
throw  out  arterial  blood.  These  constitute  the  "arterial"  form  of  the 
disease:  the  "aneurism  by  anastomosis."  And,  on  the  other  hand, 
are  tumors  formed  mainly  of  dilated,  sacculated,  and  overgrowing  veins  ; 
to  these,  arteries  of  comparatively  small  size  pass,  while  from  them 
proceed  very  large  veins  :  and  they  are  subject  to  changes  of  size  in 
all  the  events  that  affect,  not  the  arterial,  but  the  venous,  part  of  the 
circulation. 

Now,  I  believe  that,  in  a  majority  of  cases,  the  arterial  and  the  venous 
forms  of  the  disease  are  constituted  by  a  dilatation  of  large  branches, 
of  one  or  the  other  kind,  being  superadded  to  such  a  condition  of  the 
small  vessels  and  capillaries  as  exists  in  the  common,  or  "  capillary" 
erectile  tumors.  But  I  have,  also,  no  doubt  that,  in  rarer  instances, 
arterial  tumors  are  formed  by  arteries  alone,  convoluted  or  anastomos- 
ing in  a  heap,  whence,   as  from  an  arterial  "  rete  mirabile,"  normal 

*  Northern  Journ.  of  Medicine. 

f  Med.-Chir.  Trans.,  vol.  xxvi,  p.  125. 

J  Pathologische  Anatomic,  i,  276. 

^   Med.-Chir.  Trans.,  vol.  xxx,  p.  193. 

11  What  tissue  may  remain  between  the  bloodvessels  depends  on  the  seat  of  the  nsevus. 
The  elements  of  the  organ  or  tissue  in  vi^hich  it  has  its  seat  will  remain  between  its  vessels, 
wasted  or  altered  by  compression  or  defective  nutrition.  They  are  seldom  present  in  any 
distinct  form  ;  but  a  case  is  well  described  by  C.  0.  Weber,  in  which  abundant  fibrous  and 
fatty  tissue  occupied  the  space  between  the  dilated  vessels  of  an  erectile  tumor  in  a  child's 
neck  (Miiller's  Archiv,  p.  74). 


498  CAPILLARY    VASCULAR    OR    ERECTILE    TUMORS. 

arteries  proceed  and  lead  to  capillaries.  And,  on  tlie  other  hand,  there 
are,  doubtless,  venous  tumors,  which  are  formed  of  veins  alone,  and 
through  which,  since  they  are  seated  altogether  beyond  capillaries,  the 
blood  passes  (according  to  Rokitansky's  comparison)  as  it  passes  through 
a  portal  vein. 

Since  few  accounts  of  the  minute  characters  of  the  erectile  tumors 
have  been  published,  I  will  briefly  describe  those  which  I  have  examined, 
beginning  with  an  instance  of  the  medium  form,  in  a  capillary  subcu- 
taneous ngevus.* 

A  child,  2  years  old,  which  had  a  ngevus  of  this  kind  on  the  side  of 
the  chest,  died  exceedingly  emaciated  after  measles  and  diarrhoea.  The 
tumor  had  grown  from  birth-time,  and  had  appeared  as  one  of  the 
most  ordinary  subcutaneous  ngevi  or  erectile  tumors;  soft,  compressible, 
dimly  blue  as  seen  through  the  skin,  swelling  in  forced  expiration, 
thinly  scarred  over  its  centre,  in  consequence  of  an  ulcer  which  had 
spontaneously  formed  and  healed.  After  death  it  had  shrunk  into  a 
very  thin  layer  of  brownish  tissue  between  the  emaciated  skin  and  the 
fascia  covering  the  serratus  magnus.  It  was  well  defined,  and  could 
be  dissected  out  cleanly  from  the  adjacent  parts.  Its  surfaces  and 
sections  had  a  distinct  lobular  arrangement,  many  lobes  projecting  from 
its  borders,  and  those  within  it  being  separated  by  connective-tissue 
partitions  derived  from  the  tough  skin  and  fascia  between  which  the 
tumor  lay.  In  its  shrunken  state,  it  most  resembled,  in  its  obvious 
characters,  a  piece  of  parotid  gland ;  being  pale  brown  in  color,  lobu- 
lated,  soft,  but  tough,  and  yielding  but  little  blood  on  pressure. 

About  six  small  collapsed  veins  proceeded,  in  a  tortuous  course,  from 
the  surfaces  and  borders  of  the  tumor.  Its  arteries  were  too  small  to 
be  distinct.  Examined  with  the  microscope,  the  whole  mass  appeared 
composed  of  bloodvessels  interlacing  in  white  and  yellow  fibrous  tissue, 
which  probably  belonged  to  the  natural  subcutaneous  structure.  No 
parenchymal  cells  or  abnormal  forms  of  tissue  were  found ;  the  disease 
seemed  to  be  of  the  bloodvessels  exclusively. 

The  vessels,  which  were  very  difficult  to  extricate,  in  any  length,  from 
the  matted  tissue  about  them,  were  of  all  sizes,  from  2oVo*^  ^o  g^oth  of 
an  inch  in  diameter  ;  but  I  think  none  were  larger.  Nearly  all  of  them 
were  cylindriform ;  a  few  were  unequal,  or  varicose,  or  sacculated,  with 
small  pouches  projecting  from  their  walls  (Fig.  78).  I  could  not  discern 
their  arrangement ;  but  they  did  not  appear  to  branch  often ;  neither 
am  1  sure  that  they  difi"ered  in  structure  from  the  normal  vessels  of 
subcutaneous  tissue,  except  in  that  they  were,  considering  their  size,  of 
less  complex  structure :  they  were  as  if  minute  vessels  were  enlarged 
without  acquiring  the  perfect  form  of  those  which  they  equalled  in 

*  All  the  specimens  described  are  in  the  Museum  of  St.  Bartholome-w's  Hospital. 


CAPILLARY    VASCULAR     OR    ERECTILE    TUMORS. 


499 


Fig.  78.* 


calibre.  In  some  parts,  I  found  long  cords  of  connective  tissue,  "vs'liich, 
probably,  were  obliterated  bloodvessels. 

I  have  examined  other  tumors  resem- 
bling this,  but  in  less  favorable  conditions. 
From  all,  however,  as  well  as  from  the  de- 
scriptions of  others,  I  believe  the  common 
structure  of  this  form  of  erectile  tumor  is 
a  collection  of  minute  bloodvessels,  dilated, 
and  closely  arranged  within  a  limited  area 
of  some  natural  texture.  In  the  subcu- 
taneous tissue,  arteries  usually  appear  to 
pass  into  the  vascular  mass  from  the  under 
surface  of  the  skin ;  and  veins  radiate  from 
it,  larger  than  the  arteries  and  more  numer- 
ous, but  scarcely  exceeding  the  proportion 
between  the  normal  cutaneous  veins  and 
arteries.  Within  the  tumor  (which  thus,  as 
well  by  the  relation  of  its  vessels  as  by  their 
minuteness,justifies  the  epithet  "capillary") 

it  is  probable  that  some  of  the  vessels  are  always  sacculated  or  varicose. 
Virchow'sf  account  of  this  state  exactly  confirms  what  I  have  described; 
and,  with  more  detail,  Robin|  describes  an  erectile  tumor  in  which, 
along  the  track  of  the  vessels,  numerous  little  culs-de-sac  existed, 
which  the  blood  might  be  made  at  will  to  enter  and  quit,  by  alternately 
pressing  and  letting  free  a  piece  of  the  tumor  on  the  field  of  the  micro- 
scope. These  could  be  seen  on  vessels  as  small  as  |th  of  a  millimetre 
in  diameter;  they  were  generally  smaller  at  their  connection  with  the 
vessels  than  at  their  other  ends,  and  were  commonly  twice  as  long  as 
the  vessels  were  wide.§ 

But  although  the  vessels  within  the  tumor  be  thus  dilated,  yet,  as  a 
general  rule,  in  this  form  of  the  disease,  the  dilatation  (if  there  be  any) 
in  those  proceeding  to  and  from  the  tumor  extends  but  a  short  distance 
from  it :  the  arteries  enlarge  (if  at  all)  only  just  before  they  enter  the 
tumor ;  the  veins  regain  their  calibre  soon  after  they  leave  it :  and 
hence  the  general  safety  with  which  John  Bell  and  many  others  have 
cut  out  such  tumors,  when  they  attended  to  the  rule  he  lays  down  with 


*  Bloodvessels  of  the  erectile  tumor  described  in  the  text.     Magnified  about  200  times. 

f  Archiv,  fiir  Pathol.  Anatomie,  B.  iii,  p.  437. 

%  In  Lebert;  Physiologie  Pathologique.  t.  ii,  p.  99. 

§  It  may  perhaps  be  well  to  apply,  as  is  now  generally  done  by  pathologists  in  Ger- 
many, the  term  Telangeiectasis  to  these  nsevi  materni.  An  excellent  description  of  them  is 
given  by  Billroth,  in  his  Untersuch.  ttber  die  Entw.  der  Blutgefasse,  p.  69,  1856,  which  con- 
firms what  is  stated  in  the  text.  He  considers  them  as  altogether  formed  of  bloodvessels, 
partly  new-formed  and  partly  the  normal  vessels  of  the  cutis  enlarged  and  dilated.  In  the 
blae-cotored  nsevi,  the  vessels  especially  enlarged  are,  those  of  the  sebaceous  and  sweat- 
glands,  the  hair-follicles,  and  subcutaneous  fat-lobules.  In  the  bright-red  na-vi,  again,  the 
vessels  enlarged  are  those  of  the  papillae  of  the  cutis  ;  and  here,  instead  of  a  single  loop  in 
each  papilla,  as  in  the  normal  condition,  a  perfect  network  of  loops  is  met  with. 


500  ARTERIAL  VASCULAR  TUMORS. 

such  emphatic  repetition,  that  in  treating  such  a  tumor  we  are  "not  to 
cut  into  it,  but  to  cut  it  out."  However,  this  limitation  of  enlargement 
to  the  vessels  within  and  near  the  tumor,  is  not  so  usually  observed  in 
the  next  two  forms  of  the  disease,  as  in  this  which  I  have  just  described. 

The  best  example  of  the  arterial  erectile  tumor,  that  I  have  been 
able  to  examine,  was  from  a  man  who  died  under  the  influence  of  chlo- 
roform at  St.  Bartholomew's  Hospital.  He  was  23  years  old,  and  the 
disease  occupied  the  external  ear,  the  adjacent  subcutaneous  tissues, 
and  part  of  the  scalp.  The  back  of  the  auricle,  in  nearly  the  whole  ex- 
tent, was  puffed  out  by  a  superficially-lobed,  soft,  easily  compressed, 
and  elastic  swelling,  which  all  pulsated  fully  and  softly.  Two  similar 
and  continuous  lobes  of  swelling  were  under  the  scalp  above  and  behind 
the  auricle  ;  and  these  were  well  defined  above,  but  gradually  subsided 
below.  The  skin  covering  the  swelling  was  for  the  most  part  dusky 
purple,  but,  except  where  it  was  scarred,  appeared  of  healthy  texture ; 
the  skin  of  the  interior  of  the  auricle  and  its  fibro-cartilage  also  appeared 
unaffected,  except  in  the  turgescence  of  the  bloodvessels.  A  posterior 
branch  of  the  superficial  temporal  artery  passing  by  the  front  of  the 
swelling,  and  a  branch  of  the  posterior  auricular  artery  passing  behind 
it,  felt  large,  and  pulsated  strongly  ;  the  common  carotid  artery,  also, 
on  this  side,  pulsated  more  fully  than  that  on  the  other.  A  distinct 
soft  bruit  was  audible,  synchronous  with  the  pulsation  in  the  tumor ; 
and  distinct  pulsatile  movement  was  visible. 

This  disease  had  been  noticed  like  a  very  small  pimple  when  the 
patient  was  4  years  old.  It  had  from  that  time  regularly  increased. 
On  four  occasions  severe  bleeding  had  taken  place  from  it,  through  an 
ulcer  in  the  skin  over  it,  or  through  a  prominent  part  over  which  the 
skin  was  extremely  thin.  After  the  first  of  these  bleedings  a  piece  of 
the  swelling  had  been  tied,  and  had  sloughed  away.  A  month  before 
the  patient's  death,  Mr.  Lloyd  had  tied  and  compressed  the  branch  of 
the  temporal  artery  and  two  other  principal  arterial  branches  at  the 
borders  of  the  swelling ;  and  by  this  and  subsequent  treatment  had  di- 
minished the  size  of  the  tumor  and  the  fulness  of  the  pulsation  in  and 
around  it. 

Much  of  the  tumor  had  been  spoiled  by  this  treatment,  but  enough 
remained  to  show  that  a  great  part  of  its  substance  was  like  that  last 
described,  and  probably,  like  it,  consisted  of  minute  bloodvessels  col- 
lected in  a  soft  spongy  mass.  But,  while  the  veins  proceeding  from 
the  swelling  were  of  no  considerable  size,  the  arteries  passing  to  it  and 
within  it  were  very  large,  convoluted,  and  thin-walled.  This  was  espe- 
cially observed  in  the  posterior  auricular  artery,  which  had  not  been 
interfered  with  in  the  operations.  A  lobe  of  the  swelling  (as  it  seemed) 
had  pulsated  strongly  below  and  behind  the  lobule  of  the  ear  ;  and  it 
was  for  the  operation  of  tying  this  that  the  chloroform  was  given  to  the 
patient.     This  proved  to  be  only  a  part  of  the  posterior  auricular  artery, 


ARTERIAL    VASCULAR    TUMORS.  501 

which,  from  a  short  distance  beyond  its  orgin,  was  large,  and  more  col- 
lapsed and  flattened  than  the  other  branches  of  the  external  carotid. 
At  the  beginning  of  its  enlarged  part,  this  artery  was  from  a  line  to  a 
line  and  a  half  in  diameter  ;  and  from  this  point  its  trunk,  as  well  as  its 
branches  (which  were  not  unnatural  in  either  number  or  anastomosis), 
were  tortuous  and  coiled  up  in  heaps,  which  had  felt  during  life  like 
pulsating  masses.  The  dilatation  of  the  arteries  was  uniform,  not  sac- 
culated, though  in  parts  the  suddenness  of  the  curves  made  it  appear 
so.  The  small  intervals  between  them  were  filled  either  with  the 
natural  connective  tissue,  or  with  the  minute  bloodvessels  that  composed 
the  chief  mass  of  the  tumor. 

I  believe  that  this  specimen  presented  a  fair  example  of  the  ordinary 
structure  of  the  arterial  form  of  vascular  or  erectile  tumors  ;  and  that 
they  consist,  essentially,  of  the  minute  vessels  of  a  limited  portion  of 
tissue  enlarged  and  closely  clustered,  so  as  to  form  a  tumor,  in  the  sub- 
stance, as  well  as  about  the  borders,  of  which  are  arteries  much  more 
enlarged,  and  convoluted  into  pulsating  heaps. 

The  existence,  and  even  the  preponderance,  of  the  minute  vessels  in 
such  tumors  was  manifest  in  a  specimen  sent  to  me  by  Dr.  Ormerod. 
A  healthy  woman,  about  60  years  old,  had  for  many  years  a  pendulous 
growth  in  the  lower  and  inner  part  of  the  left  axilla.  Lately  it  had 
grown  quickly  to  the  size  of  the  closed  hand.  It  was  dark,  hard,  and 
knotty,  with  a  distinct  pulsation,  and  hung  on  a  pedicle  in  which  a 
large  artery  could  be  felt.  A  ligature  was  tied  on  the  pedicle,  and  a 
few  hours  after  another  was  applied,  and  the  pedicle  was  cut  through. 

The  tumor  was  gorged  with  blood,  ecchymosed,  and  too  much  da- 
maged for  complete  examination.  Its  general  aspect  was  like  that  of  the 
pedicled  outgrowths  of  skin  ;  but  nearly  its  whole  mass  consisted  of 
minute  bloodvessels  confusedly  arranged  and  of  various  sizes.  Their 
walls  showed  nuclei,  which  were  generally  shorter  than  those  of  healthy 
arteries  ;  but  in  many  instances  were  placed,  as  in  them,  regularly  in 
layers,  the  external  lying  longitudinally,  others  within  these  trans- 
versely, and,  still  within  these,  others  that  were  obliquely  or  variously 
placed.  Besides  the  bloodvessels,  I  could  find  in  the  tumor  only  a  com- 
paratively small  quantity  of  connective  tissue;  and  Dr.  Oi'merod's  ex- 
aminations, made  when  the  tumor  was  more  recent,  had  similar  results. 

Some,  I  think,  have  described  the  arterial  tumors  as  formed  by  the 
convolutions  of  a  single  artery ;  and  the  characters  of  the  swelling  formed 
by  the  trunk  and  commencing  branches  of  the  posterior  auricular  artery, 
in  the  first  of  these  cases,  make  me  ready  to  believe  that  this  descrip- 
tion may  be  sometimes  true.  But  I  think  that,  more  commonly,  many 
branches  of  arteries  are  engaged  in  the  tumor.  Such  was  the  case  in 
the  tumor  of  the  ear,  and  in  an  instance  recorded  by  Mr.  Coote.*  Ar- 
teries of  the  lip,  which,  in  their  natural  state,  might  not  have  had  a 

*  Medical  Gazette,  vol.  xlv. 


502  VENOUS  VASCULAR  TUMORS. 

greater  diameter  than  a  large  pin,  were  dilated  for  about  an  inch  of 
their  course  into  sinuses  or  canals,  and  were  equal  in  diameter  to  the 
adult  radial  artery.  Similar  to  this  was  a  very  formidable  case,  cured 
by  compression,  under  the  care  of  Mr.  Lloyd.  The  temporal,  supra- 
orbital, and  occipital  arteries,  all  exceedingly  dilated  and  tortuous,  con- 
verged to  a  large  pulsating  swelling  over  the  sagittal  suture,  the  gene- 
ral characters  of  which  agreed  exactly  with  what  I  have  described. 

In  the  arterial  vascular  tumors  the  veins  are  comparatively  small ; 
and  the  difficulty  of  transit  for  the  abundant  blood  flowing  into  them, 
doubtless  adds  materially  to  the  fulness  of  the  tumors,  and  of  the  pul- 
sations seen  and  felt  in  them.  In  the  venous  tumors  the  opposite  con- 
dition obtains  ;  the  veins  are  very  large,  the  arteries  comparatively 
small.  Of  this  kind  of  tumor  the  following  case  presented  a  good  ex- 
ample. 

A  man,  32  years  old,  was  under  the  care  of  Mr.  Lawrence.  He  had 
a  hoof-shaped  tumor  projecting'  from  the  middle  of  the  outer  part  of  his 
thigh.  It  was  from  six  to  eight  inches  in  diameter,  and  looked  like 
some  strange  outgrowth  of  skin.  Its  base  rested  on  the  fascia  lata ; 
it  was  covered  with  skin,  which  was  healthy,  except  in  one  excoriated 
place,  and  adhered  closely  to  it.  It  was  firm,  but  compressible  and 
elastic,  and  by  long-continued  pressure  could  be  reduced  to  nearly  half 
its  size,  as  if  by  squeezing  blood  from  it.  Several  small  arteries  pul- 
sated at  its  base ;  and  very  large  veins,  like  tortuous  sinuses,  converged 
from  it  towards  the  upper  part  of  the  saphena  vein. 

The  patient  was  in  feeble  health,  apparently  through  the  effect  of  a 
life  in  India,  where,  in  the  army,  he  had  received  a  wound  by  a  musket- 
ball,  to  which  he  referred  as  the  cause  of  the  growth  of  this  tumor. 
Before  the  wound,  he  believed  the  part  was  quite  healthy.  The  injury 
appeared  superficial,  and  he  was  absent  from  duty  only  two  days ;  but, 
six  months  afterwards,  he  observed  a  small  tumor,  and  this,  growing 
constantly  and  with  severe  pain,  had  increased  in  ten  years  to  the  pre- 
sent mass.  The  skin  had  been  slightly  ulcerated  for  twelve  months, 
and  severe  hemorrhages  had  occurred  from  the  ulcerated  part,  reduc- 
ing his  already  diminished  strength. 

Mr.  Lawrence  cut  away  the  whole  tumor.  Its  connections  were 
slight,  except  to  the  skin  covering  it ;  the  arteries  at  its  base  bled  freely, 
but  for  a  short  time  ;  the  great  veins  bled  very  little. 

A  section  through  the  tumor  shows  that,  while  some  parts  of  it  ap- 
peared solid  and  close-textured,  like  a  mass  of  firm  connective  tissue, 
the  greater  part  was  like  the  firmest  cavernous  or  erectile  tissue.  Sec- 
tions of  bloodvessels,  of  various  sizes  and  in  various  directions,  were  so 
thickset,  that  the  surface  looked  all  reticulated  and  grooved  with  them. 
The  general  color  of  the  tumor,  which  seemed  to  have  almost  emptied 
itself  of  blood  during  the  operation,  was  nearly  white ;   but  in  some 


ERECTILE    OR    VASCULAR    TUMORS.  503 

parts  it  had  a  pale  ruddy  tinge,  and  in  a  few  was  blotched  with  small 
rusty  and  ochrey  spots. 

The  microscopic  examination  was  less  instructive  than  the  general 
aspect  of  the  tumor.  Its  tissue  was  very  hard  to  dissect,  and  displayed 
(as  its  chief  constituent)  matted  and  crooked  fibres,  like  those  of  close- 
textured  longitudinal  striated  membrane  of  bloodvessels,  with  shrivelled 
nuclei  imbedded  in  membrane,  some  of  these  nuclei  being  round,  some 
oval,  and  some  very  narrow  and  elongated.  I  think  the  obscurity  of 
the  microscopic  appearances  was  due  to  the  tenacity  with  which  the 
bloodvessels  were  imbedded  in  the  elastic  fibrous  or  nucleated  tissue  ;  it 
seemed  impossible  to  extricate  complete  vessels ;  and  one  obtained  by 
dissection  only  fragments  of  their  walls  confused  with  the  intermediate 
tissues. 

Other  cases  of  venous  nsevi,  which  I  have  been  able  to  examine  less 
completely,  have  confirmed  the  foregoing  account,  especially  in  regard 
to  the  small  size  of  the  arteries  in  comparison  with  the  veins,  the  gene- 
rally dilated  and  varicose  state  of  the  latter,  and  the  imitation  of  the 
characters  of  erectile  tissue,  which  appears  always  more  marked  in  the 
venous  than  in  the  other  forms  of  vascular  tumors.* 

*  The  term  "  cavernous"'  is  especially  applicable  to  such  tumors  as  have  been  described 
in  the  text  by  the  name  of  venous  vascular  tumors,  and  it  is  very  much  in  that  sense  that 
it  has  been  employed  by  various  pathologists  in  Germany.  If  we  are  to  accept  the  views 
of  Rokitansky  (Sitz.  Bericht  der  Kais  ;  Akad  der  Wissen,  1852),  there  would  appear,  how- 
ever, to  be  two  forms  of  tumors  included  under  the  name  of  cavernous,  viz.,  1st,  that  form  in 
which  the  tumor  consists  essentially  of  the  bloodvessels  of  a  certain  area,  dilated,  sacculated, 
fenestrated,  with  mutual  communications;  and  2dly,  that  in  which  the  tumor  is  a  new- 
formed  cystic,  and  tubular,  or  cavernous  structure,  in  which  the  cavities  are  filled  with  blood. 
The  tumors  described  in  the  text  undoubtedly  belong  to  the  first  of  these  divisions;  so  also 
do  those  cavernous  tumors  in  the  liver  described  by  Virchow  in  his  Archiv,  vol.  vi,  p.  525. 
In  his  account  of  these  tumors,  Virchow  points  out  that  the  cavernous  tumor  of  the  liver 
grows  in  the  place  of,  and  substitutes,  certain  groups  of  the  acini ;  that  the  whole  vascular 
system  of  the  part  of  the  liver  thus  affected,  gradually  forms  a  cavernous  "ektasie,"  which 
stands  in  direct  communication  with  the  veins  and  arteries,  without  any  particular  capillary 
apparatus  being  recognizable;  that  the  process  begins  with  an  increase  of  the  intermediate 
connective  tissue  of  the  liver,  which  is  soon  followed  by  a  wasting  of  the  secreting  structure  ; 
that  in  this  tissue,  which  in  the  beginning  is  abundantly  nucleated,  the  vessels  dilate,  their 
walls  thicken,  and  blend  with  the  surrounding  connective  tissue,  and  that  then,  with  the 
increasing  dilatation  of  the  vessels,  their  walls  and  the  intermediate  tissue  atrophy,  and  in 
inseparable  connection  form  the  bars  of  the  tumor.  A  case,  described  by  Esmarch  in  Vir- 
chow's  Archiv,  vol.  vi,  p.  34,  of  multiple  cavernous  tumors  of  the  hand  and  arm,  belongs 
also,  apparently,  to  the  same  group.  So  also  does  the  case  by  Maier,  in  Virchow's  Archiv, 
vol.  viii,  p.  129,  which  almost  precisely  agrees  with  the  one  described  above,  in  the  text. 
His  description  is  more  minute  as  to  the  component  structures  of  the  intervening  bands  and 
bars,  and  more  perfectly  shows  them  to  be,  or  to  include,  venous  structures.  To  these  cases 
may  be  added  one  related  by  Busch  (Chir.  Beobacht,  1854,  p.  213). 

To  the  second  division,  in  which  the  tuinor  is  a  new  formation  of  a  blood-containing 
cavernous  system,  belongs  the  case  minutely  detailed  by  Luschka,  in  Virchow's  Archiv,  vol. 
vi,  p.  458.  It  was  an  isolated  tumor  growing  in  the  cerebrum.  He  describes  in  it  a  barred 
and  trellised  stroma  ;  the  growth  of  villiform,  clubbed,  and  other  shaped  processes  from  the 
bars  of  the  stroma;  their  hollowing  out  by  softening,  liquefaction,  and  probable  removal  of 
their  axes  and  central  substance.  He  holds  that  it  is  in  these  hoUowed-out  processes  that 
the  blood  is  contained,  only  a  few  having  as  contents  fat  granules,  cholesterine  crystals,  lime 
salts.     But  it  is  not  clearly  explained  how  the  blood  gets  into  these  processes. 


504  GENERAL    CHARACTERS    OF 

Such  are  the  principal  facts  that  I  can  cite  regarding  the  structure 
of  the  vascular  or  erectile  tumors.  They  are  very  meagre,  and  much 
is  left  for  future  inquirers  ;  especially  the  manner  in  which  the  larger 
vessels  are  connected  with  those  smaller  ones  which,  in  most  cases, 
make  up  a  chief  part  of  the  swelling ;  and  the  changes  of  structure,  if 
any,  which  exist  in  the  proper  tissues  of  the  walls  of  the  bloodvessel. 
Still,  from  even  these  few  facts  some  general  considerations  may  be 
derived. 

That  which  is  common  to  all  the  vascular  or  erectile  tumors  is  an 
over-extension  of  bloodvessels  or  blood-spaces  within  a  circumscribed 
area.  The  chief  varieties  depend  (1)  on  the  kind  of  vessels  affected, 
and  (2)  on  the  nature  of  the  tissue  in  which  these  vessels  lie.  The 
varieties  of  the  first  class  have  been  pointed  out ;  but  all  of  them  alike 
present  the  singular  instance  of  the  apparent  primary  growth  of  blood- 
vessels. In  all  other  tumors,  as  in  all  abnormal  products,  the  formation 
of  bloodvessels  appears  to  be  a  consequent  and  subordinate  process.  As 
in  the  natural  development  of  parts,  so  in  what  is  morbid,  organization 
to  a  certain  point  precedes  vascularity,  and  the  formation  of  bloodvessels 
follows  on  that  of  the  growths  into  which  they  pass.  But  here  the  case 
appears  reversed.  The  calibre  of  the  bloodvessels  increases,  and  the 
solid  tissues  between  them  diminish  ;  all  the  growth  of  an  erectile  tumor 
is  an  enlargement  of  bloodvessels,  with  diminution  of  the  tissues  in 
which  they  ramify  ;  or,  rather,  it  is  often  an  enlargement,  not  of  blood- 
vessels, but  of  blood-spaces :  for  though,  in  the  first  stages  of  the  dis- 
ease, the  walls  of  the  vessels  may  grow  and  elongate,  so  that  the  vessels 
become  tortuous,  yet,  after  a  time,  the  walls  waste  rather  than  grow ; 
apertures  seem  to  form  through  mutually  apposed  bloodvessels,  and  at 
length,  while  the  blood  within  the  tumor  increases,  the  bloodvessels 
containing  it  diminish,  together  with  the  parts  in  which  they  ramified. 
Hence,  at  last,  in  place  of  branching  and  anastomosing  tubes,  there  is 
only  a  network  formed  of  the  remains  of  their  walls.  This  is  an  increase 
of  blood-spaces  rather  than  of  bloodvessels ;  so  far  as  solid  tissue  is 
concerned,  we  might  call  it  a  wasting,  rather  than  a  growth ;  no  new 
materials  seem  to  be  added,  but  step  by  step  the  bloodvessels  are  dilated, 
and  the  intervening  tissues  clear  away,  leaving  room  for  more  and  more 
blood. 

Such  a  fact  constitutes  a  great  contrast  between  these  and  any  other 
diseases  named  tumors.  And  yet  perhaps  we  may  properly  regard 
these  as  being  overgrowths  of  bloodvessels,  comparable  with  the  over- 
growths of  the  various  other  tissues  illustrated  in  the  preceding  chap- 
ters. And  their  relation  to  such  overgrowths  seems,  sometimes,  dis- 
tinctly proved  in  the  gradations  of  morbid  changes  that  connect  them 
with  mere  enlargement  of  bloodvessels.  If  we  examine  different 
specimens  of  these  tumors,  or  sometimes  even  the  condition  of  the 
vessels  adjacent  to  one  of  them,  we  may  observe  a  regular  gradation 
from  the  erectile  tumor,  through  clusters  of  dilated  and  tortuous  vessels, 


EEECTILE     OE    VASCULAR    TUMORS.  505 

to  that  which  we  regard  as  merely  the  varicose  condition  of  the  veins 
or  arteries.  Such  transitions  are  well  shown  in  some  of  Cruveilhier's 
plates,  and  in  a  remarkable  case  by  Dr.  Hake  and  Mr.  Image  ;*  as 
well  as  in  two  of  the  cases  that  I  have  related. 

In  relation  to  the  tissues  in  which  this  overgrowth  of  bloodvessels 
may  take  place,  we  may  hold  that  there  are  two  chief  classes  of  cases. 
In  some  the  vessels  of  a  natural  part  are  affected ;  in  others  the  vessels 
of  a  new  growth.  In  the  former  class,  I  think,  are  the  greater  part  of 
the  common  erectile  tumors  of  the  skin,  and  of  the  other  parts  in  which 
they  are  most  frequently  seated ;  as  the  muscles, f  the  bones,|  the 
orbit, §  and  the  liver.  In  these  the  remains  of  natural  tissues  may  be 
found  in  the  interstices  of  the  bloodvessels,  and,  either  in  or  near  the 
tumor,  well-known  arteries  or  veins  are  involved.  In  the  latter  class, 
examples  of  which  have  been  cited  in  the  tumors  on  the  side  (p.  501) 
and  on  the  thigh  (p.  502),  the  bloodvessels  of  the  new-formed  parts  are 
affected.  To  this  class,  also,  may  be  referred,  I  think,  the  florid  and 
highly  vascular  growths  that  are  frequent  at  the  orifice  of  the  female 
urethra,  1 1  and  perhaps  many  others. 

As  I  have  hitherto  chiefly  had  in  view  the  subcutaneous  erectile  tu- 
mors or  nsevi,  so  I  will  now,  in  describing  the  general  characters  of  the 
disease,  refer  to  them  alone  for  examples.  Even  of  these,  indeed,  it  is 
difficult  to  give  a  general  account,  since  we  can  make  only  an  artificial 
distinction  between  such  as  may  bear  this  name,  and  those  extended 
dilatations  of  cutaneous  vessels  which,  with  little  or  no  swelling,  form 
the  cutaneous  nsevi,  port-wine-spots,  and  the  like.  These  are,  evidently, 
essentially  the  same  disease ;  the  terms,  cutaneous  and  subcutaneous 

*  Medico-Chirurgical  Transactions,  vol.  xxx,  p.  109. 

t  See  especially  a  case  by  Mr.  Liston,  Med.-Chir.  Trans.,  xxvi,  120;  and  one  by  Mr. 
Coote,  1.  c. ;  and  Cruveilhier,  livr.  xxx,  pi.  5. 

J  Among  these  may  be  included,  probably,  some  of  the  cases  described  under  the  name 
of  Aneurism  of  Bone  and  Osteo-Aneurism ;  as  by  Dr.  Handyside,  "  Probationary  Surgical 
Essay,"  Breschet,  and  others.  But  I  am  far  from  convinced  that,  in  all  the  cases  thus  en- 
titled, the  bloodvessels  of  the  bone  were  primarily  or  chiefly  diseased.  My  impression  is, 
that,  in  many  of  them,  the  disease  was  really  medullary  cancer  of  the  bone  with  excessive 
development  of  vessels,  and  that,  in  some,  it  was  such  a  blood-cyst  as  appears  to  be  some- 
times formed  in  the  course  of  a  myeloid  or  cancerous  disease. 

§  From  a  careful  analysis  of  some  twenty  recorded  cases  of  pulsating  tumor  in  the  orbit, 
Dr.  Joseph  Bell,  in  an  excellent  paper  in  the  Edin.  Month.  Med.  Journ.,  June,  1861,  con- 
cludes that  there  is  not  sufficient  evidence  for  believing  that  the  great  majority  of  these 
tumors  belonged  to  the  aneurisms  by  anastomosis  or  erectile  tumors.  The  sudden  accession 
of  symptoms  which  marked  the  disease  in  nearly  all  the  cases,  and  the  absence,  in  those 
which  were  examined  after  death,  of  any  indications  of  an  aneurism  by  anastomosis,  appear 
to  him  to  be  conclusive  of  the  disease  arising  from  other  causes. 

II  The  specimens  of  these  growths  which  I  have  examined  have  displayed  a  very  abun- 
dant and  tessellated  epithelium  covering  a  small  quantity  of  connective  tissue,  with  close- 
set  and  looped  bloodvessels.  This  account  is  confirmed  generally  by  M.  Verneuil,  in  the 
C.  R.  de  la  Soc.  de  Biologic,  1855,  p.  123.  But  he  describes  the  epithelium  as  cylindriform. 
In  a  case  related  by  Wed!  (Path.  Hist,  p.  409,  Syd.  Soc.  Transl.),  it  is  stated  that  the  rami- 
fications of  the  vessels  precisely  resembled  those  of  the  vasa  vorticosa. 

33 


506  GENERAL    CHARACTERS    OF 

nsevi,  respectively  applied  to  them,  imply  only  their  difference  of  seat; 
they  have  no  real  difference  of  nature,  and  are  very  often  associated. 
But,  if  we  include  only  such  as  are  for  the  most  part  or  wholly  sub- 
cutaneous, then  it  may  be  said  that  they  are  generally  round  or  oval, 
disk-shaped  or  spheroidal,  but  are  often  ill-defined,  the  morbid  state  of 
the  bloodvessels  in  which  they  consist  gradually  merging  into  the 
healthy  state  of  those  beyond  them.  Sometimes,  and  especially  in  those 
of  most  venous  character  and  of  longest  duration,  the  mass  is  circum- 
scribed by  connective  tissue,  which  forms  a  kind  of  capsule,  is  penetrated 
by  the  bloodvessels  passing  to  and  from  the  tumor,  and  is  very  intimately 
connected  both  with  the  surrounding  parts  and  with  the  tumor. 

The  vascular  tumors  are  remarkable  by  their  frequent  beginning  be- 
fore birth,  and  their  especially  quick  growth  in  early  childhood.  Beyond 
all  comparison  they  are  the  most  common  of  congenital  tumors.  Hence, 
mother-spot  is  almost  synonymous  with  nsevus,  and  n^vus  with  erectile 
tumor.  But  they  may  begin,  or  accelerate  their  growth,  at  any  period 
of  life.  I  have  seen  one  of  which  no  trace  existed  till  the  patient  was 
25  years  old ;  and  another  in  which  rapid  growth  began,  for  the  first 
time,  when  the  patient  was  past  50.  Dr.  Warren  mentions  a  case  of 
erectile  pulsating  tumor,  about  the  angles  of  the  eyes  and  forehead, 
which  began  in  a  girl  17  years  old.  Many  others,  no  doubt,  have  seen 
similar  cases. 

Their  origin  is  generally  unknown ;  but,  as  one  of  the  cases  I  have 
related  shows,  they  may  commence  in  the  results  of  injury ;  or,  rather, 
a  tumor  may  originate  in  injury,  and  in  this  tumor  an  exceeding  forma- 
tion of  bloodvessels  may  ensue. 

'Their  growth  is  uncertain ;  they  may  seem  at  rest  for  many  weeks 
after  birth,  and  then  grow  quickly,  and  then  again  may  stay  their 
growth  :  and,  having  attained  a  certain  size,  may  remain  therein  limited, 
or  may  decrease  or  disappear,  the  vessels,  in  whose  enlargement  the 
growth  consisted,  regaining  their  natural  calibre  or  becoming  obliterated. 
Their  maintenance  of  life,  if  I  may  so  term  it,  is  not  strong.  They 
are  much  more  apt  than  the  natural  tissues  are  to  slough  or  ulcerate 
after  injury  ;  and,  in  general  disturbances  of  the  health,  they  may  perish 
altogether.  I  know  of  a  case  in  which  a  large  subcutaneous  naevus  in 
a  child's  forehead  sloughed,  while  another  on  its  back,  of  much  less 
size,  was  in  process  of  sloughing  after  the  application  of  nitric  acid. 
Similar  apparently  spontaneous  sloughings  have  occurred  during,  or  in 
the  debility  following,  measles  or  scarlatina.  Such  events  may  be  con- 
nected with  the  extreme  slowness  of  the  movement  of  blood  in  the 
tumors  ;  for  though  they  contain  abundant  blood,  they  probably  trans- 
mit it  very  slowly.  Venous  tumors  not  unfrequently  contain  clots  of 
blood  and  phlebolithes ;  such,  probably,  as  would  form  only  where  the 
circulation  is  most  slow ;  and  even  in  the  arterial  tumors  the  full  pulsa- 
tion seems  to  indicate  a  retarded  stream. 

The  diseases  of  the  vascular  tumors  are  of  much  interest ;  especially 


ERECTILE    OR    VASCULAR    TUMORS.  507 

two  amongst  them, — namely,  the  formation  of  cysts,  and  that  of  malig- 
nant structures  in  their  substance. 

I  just  referred  to  the  formation  of  cysts  in  erectile  tumors,  when 
speaking,  in  Lecture  XXII,  of  serous  cysts  in  the  neck,  and  of  san- 
guineous cysts.  The  history  of  the  changes  by  which  an  erectile  tumor 
becomes  in  part  or  wholly  cystic  is  very  incomplete ;  for  the  opportu- 
nities of  observing  them,  except  when  they  are  accomplished,  are  rare. 
The  principal  facts  are,  that,  next  to  the  erectile  tumors,  those  that 
are  composed  of  clusters  of  serous  or  sanguineous  cysts  appear  to  be 
the  most  common  congenital  form,  and  that  in  some  cases  the  two  forms 
appear  in  one  mass.  I  referred,  in  Lecture  XXII  (p.  362),  to  such  a 
case  as  recorded  by  Mr.  Coote.  Mr.  Caesar  Hawkins,*  also,  had  before 
described  similar  cases.  He  says  of  one,  "  You  may  see,  in  addition  to 
the  usual  vessels,  that  several  apparent  cells  exist.  Some  of  these 
were  filled  with  coagulum  ;  their  structure  appeared  identical  with  the 
other  veins,  of  which  they  constituted,  as  it  were,  aneurismal  pouches. 
....  There  were,  however,  beside  these,  some  other  cysts,  which  con- 
tained only  serous  fluid,  and  which  were,  to  all  appearance,  close-shut 
sacs — serous  cysts — their  size  being  about  that  of  peas." 

In  other  instances,  no  erectile  or  nsevous  structure  can  be  found,  but 
the  communication  existing  between  one  or  more  among  a  cluster  of 
cysts  and  some  large  bloodvessel,  makes  it  probable  that  they  had  the 
same  origin.  Thus,  Mr.  Coote  traced  a  vein,  as  large  as  a  radial  vein, 
opening  into  the  cavity  of  a  cyst,  which  formed  one  of  a  large  cluster 
removed  by  Mr.  Lawrence  from  a  boy's  side.  The  mass  formed  by 
these  cysts  had  existed  from  birth ;  some  of  them  contained  a  serous 
fluid,  others  a  more  bloody  fluid.  In  another  similar  cluster,!  removed 
from  a  boy's  groin,  one  cyst  appeared  to  communicate  with  the  femoral 
vein,  or  with  the  saphena  at  its  junction  with  the  femoral.  In  one  case 
mentioned  by  Mr.  Hawkins, |  when  a  cyst  in  the  neck  was  opened,  ar- 
terial blood  gushed  out.  In  another,  the  patient  died  with  repeated 
hemorrhages  from  a  cyst  in  the  neck,  and  this  cyst  was  found  after 
death  to  be  one  of  several,  into  some  of  which  the  bloodvessels  of  the 
isthmus  of  the  thyroid  gland  opened. 

It  is  difiicult  to  interpret  the  formation  of  such  cysts  in  ngevi,  or  in 
connection  with  them  or  with  veins.  It  may  be,  that,  as  Mr.  Hawkins 
believes,  cysts  are  formed  in  these,  as  they  may  be  in  many  other  tu- 
mors, and  that  gradually,  by  the  absorption  produced  by  mutual  pres- 
sure, they  are  opened  into  communication  with  one  or  more  of  the  veins, 
or  of  the  sacs  connected  with  the  veins.  Or,  as  Mr.  Coote  suggests,  it 
may  be  that  certain  of  the  dilatations  of  the  vessels  are  gradually  shut 
oif  from  the  stream  of  blood,  so  as  to  form  shut  sacs  ;  and  that  after 
this  their  contained  blood  is  absorbed,  and  replaced  by  serous  fluid. 

*  Medico-Chirurgica'i  Transactions,  vol.  xxii ;  and  Medical  Gazette,  vol.  xxxvii,  p.  1027. 
f  The  specimen  is  in  the  Musuem  of  St.  Bartholomew's  Hospital. 
t  Clinical  Lectures  in  the  Medical  Gazette,  vol.  xxviii,  p.  838. 


508  RECURRENT    TUMORS. 

Lastly,  respecting  the  production  of  cancerous  disease  in  the  tissue 
of  erectile  tumors,  it  seems  to  be  generally  regarded  as  a  frequent 
event,  and  these  are  commonly  believed  to  afford  the  most  frequent  in- 
stances of  malignant  growths  supervening  on  such  as  were  previously 
innocent.  I  will  not  doubt  that  such  events  have  happened.  In  one 
case  recorded  by  Mr.  Phillips,*  the  transition  appears  to  have  been 
very  clearly  traced.  Yet,  I  think  that  in  many  of  the  cases  which 
have  gained  for  erectile  tumors  their  ill  repute,  a  clearer  examination 
would  have  proved  that  they  were,  from  the  beginning,  very  vascular 
medullary  cancers,  or  else  medullary  cancers  in  which  blood-cysts  were 
abundantly  formed.  Or,  it  may  be  that  the  erectile  tumors  have  been 
presumed  to  be  liable  to  cancer,  through  having  been  supposed  to  share 
in  the  peculiar  liability  of  the  pigmentary  nsevi,  or  moles,  to  be  the 
seats  of  melanosis. 


LECTURE   XXIX. 


RECURRENT   TUMORS. 


In  the  course  of  these  lectures  on  tumors,  I  have  pointed  out,  under 
the  head  of  each  class,  that,  after  the  complete  removal  of  one,  no 
growth  of  a  similar  nature  is  likely  to  recur  in  the  same,  or  in  any  other 
part.  And  this  is  certainly  the  rule  for  the  whole  class  of  innocent 
tumors,  and  a  character  by  which  they  are  seen  to  be  essentially  differ- 
ent from  cancers,  amongst  which  recurrence,  after  removal,  in  the 
same,  and  in  other  parts,  is  the  rule.  I  have,  however,  had  to  men- 
tion, under  several  of  the  heads  into  which  the  subject  has  been  divided, 
instances  in  which  recurrence  took  place  after  complete  extirpation. 
As  this  is  so  important  a  character,  and  one  which  possesses  so  much  in- 
terest both  practically  and  pathologically,  we  may  fairly  be  justified  in 
grouping  these  tumors  under  the  separate  head  of  Recurrent,  and  de- 
voting a  lecture  to  their  consideration. 

Almost  every  form  of  tumor  may  occasionally  present  examples  of 
recurrence,  so  that  the  distinguishing  term  I  have  employed  must  be 
understood  to  express,  not  the  possession  of  any  specific  form  or  struc- 
ture, but  rather  a  peculiar  tendency  manifested  in  the  life  of  the  tumor. 
For  it  may  be  accepted  as  a  well-established  fact,  both  in  physiology 
and  pathology,  that  similarity  of  structure  between  two  or  more  differ- 
ent parts  is  not  of  itself  sufficient  to  determine  functional  correspon- 
dence. The  examination,  therefore,  of  any  texture,  either  morbid  or 
healthy,  cannot  be  regarded  as  complete  if  it  is  limited  to  a  mere  deter- 
mination of  its  form,  appearance,  and  structure.     Its  growth,  develop- 

*  On  Vascular  Tumors,  in  the  Medical  Gazette,  vol.  xii,  p.  10. 


RECURRENT    TUMORS.  509 

ment,  tendencies,  influences  upon  the  individual  in  whom  it  occurs,  in 
short,  its  life,  must  be  attended  to.  Its  teleological  as  well  as  its  mor- 
phological aspects  are  to  be  considered. 

I  have  already  described  (p.  386)  instances  in  which  proliferous  cysts 
recurred  after  removal.  At  p.  457  e.  s.,  several  cases  have  been  men- 
tioned in  which  cartilaginous  tumors  returned  not  only  in  the  same 
part,  but  even  appeared  in  distant  organs.  Recurrence  and  secondary 
deposits  of  the  myeloid  tumors  have  now  been  described  in  more  than 
one  instance  (pp.  471,  510,  notes),  and  the  mammary  glandular  tumors 
have  occasionally  returned  after  removal  (p.  492).  The  fibro-cellular 
tumors,  and  those  growths  of  mucous  tissue  already  adverted  to  (p.  415), 
also  present  additional  illustrations. 

But  the  form  of  tumor  in  which  this  property  of  recurrence  is  most 
strongly  exemplified,  is  one  which  in  its  structure  most  nearly  resem- 
bles that  of  the  common  fibrous  tumors,  and  for  it  I  have  proposed  the 
name  of  "  Recurrent  Fibroid  Tumor." 

Although  the  various  instances  of  recurrent  tumors  recorded  present 
many  diversities  of  structure,  yet  they  may  be  said  generally  to  have  pos- 
sessed the  characters  of  incomplete  development,  and  to  hare  approxi- 
mated to  the  embryonic  or  rudimental,  rather  than  the  perfect  state  of 
the  natural  tissues.  And  this  rule  of  persistent  or  arrested  embryonic 
structure  in  the  recurrent  tumors  is  so  general,  that  in  practice  it  is 
advisable  to  speak  with  hesitation  of  the  ultimate  result  of  any  case  in 
which  a  tumor  is  found  to  be  composed  of  rudimental  tissues.  This 
similarity  in  structure  to  embryonic  texture  becomes  more  strongly 
marked  after  each  removal  and  recurrence.  So  that  a  tumor  which,  at 
first,  might  be  not  unlike  the  normal  fibrous  or  glandular  texture  in 
which  it  grew,  after  repeated  removal  and  recurrence  becomes  softer, 
more  succulent,  and  in  its  later  growths  may  seem  to  the  naked  eye 
little  more  than  like  masses  of  yellow  or  ruddy  soft  gelatine  with  blood- 
vessels.* The  later  are  usually  much  more  rapid  in  their  progress  than 
the  earlier  growths :  they  are  generally  less  well  defined,  penetrating 
farther  and  more  vaguely  among  the  interstices  of  adjacent  parts,  and 
more  quickly  protruding  through  the  skin  or  scars  over  them. 

And  in  these  characters  the  later-formed  tumors  assume  more  of  the 
character  of  malignancy  than  the  earlier.  In  the  case  I  relate  on  p. 
511,  the  last  tumor  was,  in  general  aspect,  hardly  to  be  distinguished 
from  brain-like  tumor,  though  in  microscopic  characters  essentially 
like  its  predecessors.  In  one  of  Professor  Gluge's  cases  the  transitions 
to  completely  malignant  characters  appeared  yet  more  sure.  Mr.  Syme 
also  expresses  a  similar  transition  :  describing,  as  the  usual  course  of 
the  cases  he  has  seen,  that  after  one  or  two  recurrences  of  the  tumor, 
the  next  new  productions  present  a  degeneration  of  character,  excite 

*  An  excellent  illustration  of  this  change  from  the  normal  type  of  the  texture  to  a  more 
rudimental  form,  is  presented  by  the  case  of  cylindroma  recorded  by  Busch  and  Billroth. 
Note,  p.  415. 


510  EECURRENT    TUMORS. 

pain,  proceed  to  fungous  ulceration,  and  thus  in  the  end  prove  fatal. 
So  that,  although  there  be  cases  in  which  this  evil  career  has  not  been 
run,  yet  I  think  we  may  regard  these  tumors  as  approximating  to 
characters  of  malignancy,  not  only  in  their  proneness  to  recurrence 
after  removal,  but  in  their  aptness  to  assume  more  malignant  features 
the  more  often  they  recur.  Whatever  be  the  truth  concerning  the  sup- 
posed transformation  of  an  innocent  into  a  malignant  morbid  growth,  I 
think  it  can  hardly  be  doubted  that  in  the  cases  of  some  recurring  tumors 
the  successively  later  growths  acquire  more  and  more  of  the  characters 
of  thoroughly  malignant  disease.* 

But  this  evil  result  does  not  by  any  means  follow  as  a  necessary  con- 
sequence of  the  repeated  recurrence  of  the  tumor,  for  there  are  many 
cases  now  recorded  in  which  the  patient  retains,  to  all  appearances, 
perfectly  good  health,  and  shows  none  of  that  cachexia  which  would 
almost  certainly  exist  in  a  patient  who  had  suffered  repeated  recurrences 
of  cancer.  'Ho  more  striking  example  could  be  adduced  in  illustration 
than  the  case  related  by  Dr.  Douglas  Maclagan,  and  described  farther 
on,  in  which  the  tumor  appeared  upwards  of  thirty  years  ago,  recurred, 
and  was  removed  three  times,  with  considerable  intervals  between  each 
recurrence,  and  yet  the  patient  is  still  in  perfect  health. 

The  recurrence  of  these  tumors  takes  place,  not  merely  in  the  same 
organ  or  tissue,  but  in  loco — in  the  place  in  which  they  originally 
occurred — in  the  cicatrix,  or  closely  adjacent  to  the  scar  of  the  first 
operation  wound.  And  here,  again,  do  they  possess  a  character  by 
which  they  are  distinguished  from  the  malignant  tumors,  which  in  their 
recurrence  may  multiply  not  only  in  the  same  part  but  in  distant  organs. 
Cases  certainly  have  been  recorded,  more  especially  of  some  cartilagin- 
ous tumors  (note,  p.  458),  in  which  growths  of  the  same  nature  arose  in 
distant  parts,  as  the  lungs,  but  in  them  there  is  distinct  evidence  of  the 
growth  being  propagated  along  the  lymphatics  into  the  veins,  and  then 
into  the  pulmonary  artery  and  its  minute  branches. f 

Thus  we  have  in  these  recurrent  tumors  characters  which  connect 
them  on  the  one  hand  with  the  innocent,  and  on  the  other  with  the  ma- 
lignant tumors,  so  that  the  plan  I  have  adopted  of  placing  them  in  a 
group  intermediate  between  those  two  great  divisions  seems  not  inex- 
pedient.    And  this  relation  to,  and  partial  possession  of,  the  characters 

*  An  illustration  is  presented  by  a  remarkable  case,  of  which  specimens  are  described  in 
Cat.  Mus.  St.  Bartholomew's,  Ser,  xxxv,  Nos.  28,  29.  Other  examples  are  adduced  in  the 
recurring  proliferous  cysts,  p.  387,  and  in  a  case  of  recurring  fibroid  recorded  by  Mr.  Hulke, 
Med.  Times  and  Gazette,  Nov.  29,  1862. 

f  Dr.  Wilks  also  has  recorded  a  case  (Path.  Trans.,  vol.  x,  p.  244)  of  a  man  whose  leg 
was  amputated  by  Mr.  Cock,  for  a  large  myeloid  tumor  of  the  head  of  the  fibula.  Two  years 
afterwards  a  recurrence  took  place  in  the  stump.  Removal  was  again  performed,  and  a 
few  days  afterwards  the  man  died  of  pleurisy.  At  the  post-mortem  examination,  secondary 
myeloid  tumors,  of  considerable  size,  were  hanging  pendulous  from  the  exterior  of  the  lungs, 
but  not  infiltrating  their  substance.  But  the  more  frequent  result  of  amputations  for  recurrent 
tumors  of  the  limbs,  has  been  an  apparently  final  remedy. 


RECURRING    FIBROID    TUMORS. 


511 


common  to  the  two  divisions,  appears  to  be  in  some  measure  accounted 
for  by  these  recurrent  tumors  being  so  frequently  found  in  members  of 
cancerous  families.  I  have  seen  several  cases  in  which  these  tumors 
occurred  in  the  descendants  or  near  relatives  of  those  who  are,  or  have 
been,  cancerous,  and  I  have  heard  and  read  of  others  like  them ;  from 
which  I  have  been  led  to  form  the  opinion,  that,  amongst  the  members 
of  families  in  which  cancer  has  manifested  itself,  there  is  a  peculiar 
liability  to  the  production  of  tumors,  which  will  recur  after  repeated 
and  complete  excisions,  though  they  are  neither  cancerous  in  structure, 
nor  attended  with  similar  disease  in  the  lymphatic  or  other  organs ;  nor 
with  any  cachexia  but  such  as  may  be  ascribed  to  their  gradual  influ- 
ence upon  the  constitution.* 

With  these  general  remarks  on  the  group  of  recurrent  tumors,  I  shall 
now  proceed  to  a  more  detailed  account  of  those  which  I  have  termed 
Recurrent  Fibroid,  and  among  which,  although  the  general  characters 
of  the  group  are  equally  well  marked  among  those  of  other  rudimental 
structures,  the  most  striking  examples  have  been  found. 

A  brief  account  of  some  cases  of  this  tumor  may  best  illustrate  it. 

The  first  I  saw  was  from  a  gentleman,  60  years  old,  under  the  care 
of  Mr.  Stanley.  In  1846  a  tumor  was  removed  by  Mr.  Cockle  from 
the  upper  and  outer  part  of  his  leg.  It  lay  close  to  the  tibia,  was  as 
large  as  a  filbert,  and  was  considered  fibrous.  Some  months  afterwards 
another  tumor  was  found  in  the  same  place,  and,  when  as  large  as  a 
walnut,  was  removed  by  Mr.  Hamilton,  of  the  London  Hospital,  who  con- 
sidered it  "  decidedly  fibrous."  In  October,  1847,  Mr.  Stanley  removed 
from  the  same  place  a  third  tumor ;  and  this  I  examined  minutely.  It 
had  the  shape,  and  nearly  the  size,  of  a  patella,  and  the  note  that  I  made 
of  its  general  appearance  was,  that  it  was  "  very  like  those  fibrous  tumors 
which  are  whitest,  most  homogeneous,  and  least  fasciculate  and  glis- 
tening;" and  that  "with- 
out the  microscope  I  should  ^^S-  79.t 
certainly  have  called  it  a 
fibrous  tumor." 

The  microscopic  exami- 
nation, however,  showed 
peculiar  structures  (Fig. 
79).  The  tumor  was  com- 
posed almost  entirely  of 
very  narrow,  elongated, 
caudate,     and    oat-shaped 

nucleated  cells,  many  of  which  had  long  and  subdivided  terminal  pro- 
cesses.   Their  contents  were  dimly  shaded  ;  and  in  many  instances  the 


*  For  a  more  detailed  account  of  the  relations  of  recurrent  to  cancerous  tumors,  I  may 
refer  to  a  paper  in  the  Medical  Times  and  Gazette.  August  22, 1857. 

f  Fig.  79,  microscopic  elements  of  a  recurring  fibroid  tumor  described  above.  Magni- 
fied about  400  times. 


512  RECURRING    FIBROID    TUMORS. 

nuclei  appeared  to  swell  out  the  body  of  the  cell,  as  in  the  most  elongated 
granulation-cells.  With  these  cells  were  scattered  free  nuclei,  and  gru- 
mous  or  granular  matter,  such  as  might  have  been  derived  from  dis- 
integrated cells.  Very  little  filamentous  tissue  was  contained  in  any 
part  of  the  tumor. 

Now,  in  the  extirpation  of  the  third  tumor,  the  parts  around  it  were 
very  freely  removed,  the  periosteum  was  scraped  from  the  tibia,  and 
every  assurance  seemed  to  exist  that  the  whole  disease  was  cleared  away. 
But,  in  June,  1848,  two  small  tumors  appeared  in  the  subcutaneous 
tissue  just  below  the  seats  of  the  former  operations.  These  also  were 
removed,  and  these  had  the  same  fibrous  appearance,  and  the  same  mi- 
nute texture,  as  the  preceding.  Some  months  only  elapsed  before  in 
the  same  place  another  tumor  grew ;  i.  e.  a  sixth  tumor.  The  patient, 
despairing  of  remedy  by  operations,  allowed  this  to  grow  till  Novem- 
ber, 1850,  by  which  time  it  had  acquired  a  diameter  of  between  four 
and  five  inches,  and  protruded  as  a  large  soft  fungoid  mass  from  the 
front  of  the  leg.  Two  profuse  hemorrhages  occurred  from  it,  and 
made  him  earnestly  beg  that  his  limb  might  be  removed  to  relieve  him 
from  the  extreme  misery  of  his  disease.  The  amputation  was  per- 
formed, and  he  died  in  a  few  days. 

The  tumor*  appeared  confused  with  the  thin  skin  over  it.  It  rested 
below  on  the  muscles  of  the  leg,  but  was  not  mixed  with  them,  except  at 
a  scar  from  the  former  operations.  The  tumor  was  milk-white,  soft, 
and  brain-like,  except  where  discolored  by  eflfused  blood,  and  in  the  ex- 
posed parts  was  soft,  pulpy,  and  grumous.  One  would  certainly,  judg- 
ing by  its  general  aspect,  have  called  this  a  brain-like  medullary  can- 
cer ;  and  yet  it  had  essentially  the  same  microscopic  characters  as  the 
tumors  I  first  examined  from  the  same  patient :  only,  the  narrow,  elon- 
gated, caudate  cells  were  very  generally  filled  wdth  minute  shining 
molecules,  as  if  from  fatty  degeneration  connected  with  the  protrusion 
and  partial  sloughing  of  the  mass.  Unfortunately,  no  examination  of 
the  body  was  made  after  death,  and  it  could  only  be  guessed,  from  the 
absence  of  emaciation,  and  of  all  other  indication  of  general  loss  of 
health,  that  no  similar  disease  existed  in  internal  organs. 

In  another  case  of  the  same  kind,  I  assisted  Mr.  Stanley,  in  May, 
1848,  in  the  removal  of  a  tumor  from  the  shoulder  of  a  gentleman 
twenty-eight  years  old.  It  had  been  growing  under  the  deltoid  for  six 
months,  was  loosely  connected  with  the  surrounding  parts,  and  was 
about  three  inches  in  diameter.  It  had  the  general  aspect  of  a  com- 
mon fibrous  tumor :  firm,  tough,  white,  traversed  with  irregular  bands. 
It  was  easily  and  complely  removed,  but  was  not  examined  with  the 
microscope.  The  wound  of  the  operation  healed  well ;  but,  two  months 
afterwards,  a  second  tumor  appeared  under  the  cicatrix.  This  was  re- 
moved with  some  of  the  adjacent  muscles,  and  other  tissues.     It  was 

*  In  the  Museum  of  St.  Bartholomew's. 


RECURRING    FIBROID    TUMORS.  513 

like  the  first,  only  less  tough,  and  more  lobed,  and  elastic ;  but  under 
the  microscope,  instead  of  appearing  fibrous,  it  was  found  to  be  com- 
posed almost  entirely  of  elongated  and  caudate  nucleated  cells,  very 
like  those  described  in  the  last  case,  and  mixed  with  free  nuclei  and 
granular  matter. 

In  March,  1849,  a  third  tumor  was  removed  from  the  same  part, 
which  had  been  noticed  two  months,  and  again  presented  the  same 
character ;  it  was  indeed  grayer,  and  less  firm,  and  more  shining  and 
succulent  on  its  cut  surfaces,  but  the  differences  to  the  naked  eye  were 
not  great,  and  the  microscopic  structure  was  the  very  same  as  in  the 
former  instance. 

In  October,  1849,  another  tumor  had  formed,  and,  after  it  had  re- 
sisted various  methods  of  treatment,  Mr.  Stanley  removed  it,  by  a  fourth 
operation,  in  December,     This  had  again  the  same  character. 

In  the  course  of  1850,  a  fifth  tumor  appeared  in  the  same  part,  and 
this,  after  growing  slowly  for  an  uncertain  time,  ceased  to  increase,  and 
has  now  been  for  a  long  time  stationary,  without  in  any  way  interfer- 
ing with  the  patient's  health.  He  is  pursuing  an  active  occupation, 
and,  but  for  the  tumor,  might  be  thought  a  healthy  man. 

In  a  third  case,  Mr.  Syme  removed,  in  1839,  a  tumor  which,  without 
any  known  cause,  had  been  growing  for  a  year,  over  the  anterior  part 
of  the  first  right  rib  of  a  gentleman  48  years  old.  Two  years  after  the 
operation,  another  tumor  appeared  in  or  near  the  same  part,  and  was 
removed  by  Mr.  Syme  in  1843.  A  third  was  removed  by  him  in  1847; 
and  a  fourth  in  1849.  After  another  distinct  interval  of  apparent 
health,  a  fifth  tumor  appeared,  and  grew  quickly,  and  was  removed  by 
the  same  gentleman  in  1851.  In  one  of  these,  an  account  of  which  was 
published  by  Mr.  Syme,  Dr.  Hughes  Bennett  found  microscopic  struc- 
tures similar  to  those  of  the  fibro-plastic  tumors  of  Lebert  ;*  similar, 
therefore,  I  have  no  doubt,  to  those  described  above.  The  patient  re- 
covered from  the  last  operation,  as  from  all  the  previous  ones,  quickly 
and  favorably ;  but  the  Avound  had  scarcely  healed  when  two  more  tu- 
mors appeared  beneath  the  scar,  like  the  preceding  ones,  except  in  that 
they  grew  more  rapidly. 

One  of  these  tumors  was  so  firmly  fixed  at  the  clavicle  that  no  further 
operation  could  be  recommended.  In  six  months'  growth  the  tumors, 
at  first  distinct,  had  formed  a  single  mass,  deeply  lobed,  of  oval  form, 
measuring  a  foot  in  one  direction,  and  about  ten  inches  in  the  other. 
It  covered,  and  felt  as  if  tightly  fixed  to,  the  middle  half  of  the  clavicle, 
and  thence  extended  downwards  over  the  chest,  and  outwards  towards 
the  axilla.  It  felt  heavy,  firm,  tense,  and  elastic.  The  skin,  thinly 
stretched  over  it,  and  by  its  tension  appearing  as  if  adherent,  was  gene- 
rally florid,  but  in  some  parts  livid,  and  over  the  most  prominent  lobes 

*  Monthly  Journal  of  Medical  Science,  vol.  x,  p.  194.  Probably  this  refers  to  the  elon- 
gated cells  alone.  I  have  not,  in  any  of  these  tumors,  found  the  large  many-nucleated  cells 
which  occur  in  most  of  the  tumors  named  fibro-plastic  by  M.  Lebert. 


514  RECURRING    FIBROID    TUMORS. 

ulcerated ;  but  the  principal  ulcers  were  superficial,  covered  with  healthy- 
looking  granulations,  discharging  thick  pus,  having  no  cancerous  or  other 
specific  character  :  only  one  of  them  had  a  thin  slough.  Such  were  the 
characters  of  the  disease  when  I  saw  it  in  February,  1852,  and  it  was 
very  striking,  as  evincing  one  of  the  contrasts  between  this  form  of 
tumor  and  any  rapidly-growing  ulcerated  cancer,  that  the  patient's 
general  health  was  scarcely  affected.  He  was  still  a  florid,  sturdy  man ; 
and  he  fed,  slept,  talked,  and  moved  about  as  a  man  in  health  might  do. 
He  suffered  scarcely  any  pain  ;  but,  within  the  last  month,  the  ulcerated 
surface  of  the  tumor  had  bled  severely.  The  tumor  was  now  submitted 
to  compression,  with  Dr.  Neil  Arnott's  apparatus ;  and  with  some  ad- 
vantage, inasmuch  as  its  growth  was  retarded,  and  the  hemorrhage  was 
prevented,  so  long  as  the  pressure  was  maintained.  Twice,  however, 
on  the  instant  of  removing  the  apparatus,  I  saw  arteries  as  large  as  the 
radial  throw  blood  in  a  jet  far  from  the  trunk.  The  bleeding  was  in 
this  respect  such  as  I  have  never  seen  from  the  proper  vessels  of  any 
other  tumor,  and  was  like  that  described  as  occurring  in  the  first  of 
these  cases. 

It  would  be  useless  to  tell,  at  any  length,  the  later  history  of  this 
case.  The  tumor  increased  constantly  to  the  time  of  the  patient's 
death  in  July,  1852  ;  but,  in  the  last  two  months,  several  small  portions 
of  it  sloughed  away,  and  it  gradually  shifted  lower  down  on  the  chest, 
leaving  the  clavicular  region,  so  that  at  the  time  of  death  it  lay  movable 
on  the  muscles,  and  could  be  removed,  "as  a  common  fatty  tumor  might 
be,"  without  dividing  any  important  part :  death  seemed  due  to  mere 
exhaustion,  consequent  on  the  discharge  from  the  tumor,  and  the  pain 
to  which,  as  it  extended  farther  into  the  axilla,  it  gave  rise.  Dr.  Ross, 
to  whom  I  am  indebted  for  an  account  of  the  conclusion  of  the  case. 

Pig.  80.* 


could  find  no  indication  of  disease  in  any  internal  organ.  Only  the 
tumor  was  allowed  to  be  examined  after  death ;  and  Dr.  E,oss  wrote  to 
me  of  it,  in  addition  to  the  account  of  the  absence  of  any  deep  connec- 
tion or  infiltration  of  adjacent  tissues,  that  "its  texture  was  pretty 

*  Fig.  80,  microscopic  structures  of  the  recurring  fibroid  tumor  described  above.     Mag- 
nified 450  times. 


RECURRING    FIBROID    TUMORS.  515 

hard,  like  that  of  a  fibrous  tumor,  but  not  nearly  so  dense  or  crisp  as 
scirrhus.  It  scarcely  gave  out  any  blood  on  being  cut  into ;  but  here 
and  there  was  to  be  seen,  on  the  surface  of  a  section,  the  open  mouth 
of  a  vessel,  just  as  in  a  section  of  liver.  All  the  textures  behind,  form- 
ing the  bed  of  the  tumor,  appeared  quite  healthy." 

A  portion  of  the  tumor,  kindly  sent  to  me  by  Dr.  Ross,  was,  after 
having  lain  in  spirit,  milk-white,  firm,  elastic,  of  very  close  texture, 
breaking  and  tearing  with  a  coarse  fibrous  grain.  It  had,  most  nearly, 
the  aspect  of  a  very  firm  fibro-cellular  tumor  altered  by  spirit.  When 
scraped  it  yielded  little  or  no  fluid,  but  white  shreds,  in  which,  together 
with  much  that  looked  like  withered  tissue  or  debris,  there  were  abun- 
dant slender  awn-shaped  corpuscles,  such  as  are  sketched  in  Fig.  80. 
They  looked  dry  and  shrivelled,  containing  no  distinct  nuclei,  but  mi- 
nute shining  particles,  as  if  themselves  were  outgrown  nuclei.  With 
these,  also,  were  numerous  broader  and  shorter  corpuscles,  of  the  same 
general  aspect,  but  inclosing  oval  nuclei ;  and  yet  more  numerous 
smaller  bodies,  like  shrivelled,  oval,  elongated,  free  nuclei,  dotted,  and 
containing  minute  shining  particles.  The  whole  mass  appeared  made 
up  of  corpuscles  of  these  various  shapes,  irregularly  or  lineally  im- 
bedded in  a  substance  that  was  nearly  structureless  or  imperfectly 
fibrillated.  Only  in  a  few  places,  perhaps  in  the  partitions  of  the  lobes, 
there  was  a  very  small  quantity  of  fine  connective  tissue. 

I  think  there  can  be  no  doubt  that  this  case  was  essentially  of  the 
same  kind  as  the  former  two  ;  and  the  constancy  of  their  peculiarities 
in  both  history  and  structure  appears  sufficient  to  justify  the  placing 
them  in  a  separate  group  and  under  a  separate  title.  But  these  are 
not  the  only  cases  to  be  cited. 

Professor  Gluge  has  given  a  good  general  account  of  the  history  of 
such  tumors  as  these,  as  examples  of  the  forms  transitional  to  cancer. 
He  names  them  "albuminous  sarcoma;"  a  term  one  hears  frequently 
used,  without,  perhaps,  any  clear  meaning ;  yet  generally,  I  think,  with 
the  suspicion  that  the  growths  to  which  it  is  applied  are  not  wholly 
innocent.  Among  the  cases  which  he  cites,  one  coincides  exactly  with 
those  I  have  detailed.  A  major,  45  years  old,  fell  from  his  horse,  in 
1843.  Six  or  seven  weeks  afterwards,  a  tumor  appeared  over  his 
scapula.  It  was  removed,  but  after  some  months  returned.  Between 
1843  and  1848,  four  such  tumors  were  removed  from  the  same  part. 
In  1848,  the  patient  was  under  the  care  of  M.  Seutin,  who  removed  the 
fifth  tumor ;  and  Gluge's  description  of  this,  including  the  expression 
that  in  color  and  consistence  it  was  like  the  muscular  tissue  of  the  in- 
testinal canal,  leaves  little  doubt  that  it  was  like  the  less  firm  of  the 
specimens  that  I  have  been  describing.  In  the  last  of  these  five  opera- 
tions, and  in  one  previously,  the  removal  of  the  tumor  was  followed  by 
free  cauterization  of  the  wound ;  yet  the  last  account  published  by 
Professor  Gluge  was,  that  in  April,  1849,  a  sixth  tumor  had  appeared 


516  RECURRING    FIBROID    TUMORS. 

in  the  same  part ;    and  lie  has  informed  me  hj  letter  that  in  1850  the 
patient  died. 

Lastly,  a  case  which,  in  its  conclusion,  is  the  most  instructive  of  all 
that  have  been  recorded,  is  related  hj  Dr.  Douglas  Maclagan.* 

A  girl,  22  years  old,  had  a  tumor,  of  three  years'  growth,  on  the  left 
lumbar  region,  about  an  inch  from  the  spine.  In  1832,  it  was  about  as 
large  as  a  Jargonelle  pear,  firm,  but  elastic  and  movable,  and  below  it 
was  a  portion  of  indurated  skin.  The  tumor  and  diseased  skin  were 
removed,  and  the  former  "possessed  most  of  the  characters  of  a  simple 
fibrous  tumor."  After  about  twelve  months  the  disease  returned  in  the 
scar.  Three  little  tumors  formed,  and  these,  with  the  scar,  were  re- 
moved freely,  in  February,  1834.  "  The  extirpated  mass  bore  a 
striking  resemblance  to  that  previously  removed."  Between  twelve 
and  eighteen  months  later,  a  third  growth  appeared,  which,  after  in- 
creasing for  a  year  and  a  half,  was  removed.  "  It  had  the  same  elastic 
feel  and  fibrous  appearance ;  and  the  semi-transparent  pinkish  gray 
color  was  the  same  as  in  the  original  tumor."  In  March,  1857,  Dr. 
Maclagan  sent  me  a  portion  of  another  tumor  cut  out  from  the  same 
place  in  this  patient,  by  Mr.  Spence.  "  The  specimen  presented  to  the 
naked  eye  exactly  the  same  appearance  which  the  former  tumors  did." 
On  microscopic  examination  it  was  exactly  after  the  type  of  the  recur- 
rent fibroid  tumors,  and  in  naked-eye  appearance  just  like  the  others 
that  I  have  seen.  Dr.  Maclagan  kindly  writes  me,  "that  at  the  pre- 
sent time  (November,  1862,  thirty  years  after  the  removal  of  the  first 
tumor)  she  is  in  perfect  health,  and  daily  follows  her  avocation  as  a 
laundress.  Since  1857  there  has  been  no  further  recurrence  of  the 
tumor." 

Dr.  Maclagan  has  added  the  account  of  another  case,  in  which  the 
essential  features  were  quite  similar ;  and  another,  which  I  believe  must 
be  referred  to  this  group,  is  accurately  described  and  figured  by  Dr. 
Hughes  Bennett.f 

During  the  past  ten  years  the  literature  of  these  recurring  fibroid 
tumors  has  received  considerable  additions  by  the  publication  in  various 
quarters  of  numerous  cases  which  have  fallen  under  the  notice  of  difi"er- 
ent  surgeons.  To  some  of  these  it  may  be  convenient  to  give  the  re- 
ferences. Mr.  Birkett  in  Guy's  Hospital  Reports,  Ser.  iii,  vol.  iv; 
Mr.  Hutchinson,  Med.  T.  and  Gaz.,  August  20,  1853 ;  Billroth,  Vir- 
chow's  Archiv,  B.  viii,  1855;  Verneuial,  Mem.  de  la  Soc.  de  Biologic, 
1855 ;  Mr.  Callender,  Trans.  Path.  Soc,  vol.  ix,  p.  327  ;  Dr.  Roberts, 
Beale's  Archives,  October,  1861 ;  Mr.  Annandale,  Edin.  Med.  Jal., 
p.  432,  1862;  Mr.  C.  Heath  and  Mr.  Hulke,  Med.  T.  and  Gaz.,  Nov. 
18,  1862. 

*  Edinburgh  Medical  and  Surgical  Journal,  vol.  xlviii,  1837. 
t  On  Cancerous  and  Cancroid  Growths,  p.  87 


FIBRO-NUCLEATED    TUMORS.  517 

FlBRO-NUCLEATED  TuMORS. 

Dr.  Hughes  Bennett*  has  given  the  name  of  Fihro-nudeated  to  cer- 
tain tumors,  first  described  by  himself,  of  which  I  think  that  future 
investigations  will  prove  a  very  near  affinity  with  those  which  I  have 
been  considering.  They  are,  indeed,  of  so  rare  occurrence,  that  we 
cannot  as  yet  be  sure  of  many  things  concerning  them  ;  but  their  most 
usual  characters  seem  to  be,  as  assigned  by  Dr.  Bennett,  a  general  re- 
semblance to  the  fibrous  tumors  ;  a  tendency  to  return  in  the  part  from 
which  one  has  been  excised ;  an  absence  of  disposition  to  aflFect  lym- 
phatics or  more  distant  parts ;  and  a  texture  "  consisting  of  filaments 
infiltrated  with  oval  nuclei."  The  first  three  characters  are  repetitions 
of  those  belonging  to  the  recurring  fibroid  tumors  ;  the  last  is  not  so  ; 
and  yet  the  difference  of  structure  is  such  as  may  consist  of  a  very  near 
natural  relationship.  For,  as  we  have  seen,  both  cells  tending  to  elon- 
gate and  attenuate  themselves  into  filaments,  and  nuclei  imbedded  in  a 
simple  or  filamentous  blastema,  are  equally  forms  through  which  fibro- 
cellular  or  fibrous  tissue  may  be  developed  (see  p.  140,  &c.).  And 
thus  it  may  be  that,  in  these  two  groups  of  tumors,  the  similarly  con- 
trasted forms  of  elemental  structure  may  be  nearly  related,  in  that  both 
alike  represent  persistently  imperfect  developments  of  fibrous  masses. 

However  this  may  be,  the  history  of  these  cases  is  important,  espe- 
cially because,  like  the  last  described,  they  seem  to  occupy  a  kind  of 
middle  ground  between  innocent  and  malignant  tumors.  They  are 
among  the  diseases  which  are  often  spoken  of  as  "  semi-malignant," 
"locally  malignant,"  or  "less  malignant  than  cancer:"  terms  which 
are  generally  used  in  relation  to  what  are  deemed  exceptional  cases, 
but  which  may  appear  to  have  a  real  meaning  if  ever  we  can  apply 
them  to  well-defined  groups  of  tumors. 

The  most  characteristic  of  the  cases  described  by  Dr.  Hughes  Ben- 
nett, was  that  of  a  lady  25  years  old,  from  whom,  when  she  was  18,  a 
tnmor  of  four  years'  growth  was  removed  from  the  left  thigh,  nearly  in 
front  of  the  great  trochanter.  After  its  removal  there  remained  a  small 
hard  knot  in  the  scar ;  but  no  change  ensued  in  this  for  six  years. 
Then  it  began  to  enlarge  and  increase,  and  in  a  year  increased  to  the 
size  of  a  small  almond-nut.  It  was  superficial,  quite  movable,  and  in- 
timately adherent  to  the  skin.  It  was  hard  and  dense ;  and  its  cut 
surface  was  smooth,  slightly  yellowish,  and  yielded  no  juice  on  pressure. 
It  appeared  to  consist  of  fine  filaments,  among  which  oval  bodies,  like 
nuclei  with  nucleoli,  were  everywhere  infiltrated.  Here  and  there  large 
oval  rings  appeared,  marked  by  converging  irregular  lines,  and,  in  a 
few  places,  oval  spaces  surrounded  with  concentric  marks,  like  sections 
of  gland-ducts. 

The  only  well-marked  case  that  I  have  yet  seen  w^as  that  of  a  boy, 
10  years  old,  on  the  palmar  aspect  of  whose  fore-arm  a  small  indenta- 
tion was  noticed  at  birth.     This  part  was  slightly  wounded  when  he 

*  On  Cancerous  and  Cancroid  Growths,  p.  176,  &c. 


518 


FIBRO-NUCLEATED     TUMORS. 


"was  two  years  old,  and  from  that  time  a  tumor  began  to  grow.  When 
he  was  four,  the  tumor  was  removed  (of  course  completely)  by  Mr. 
Sands  Cox,  but  the  wound  did  not  heal  before  another  growth  appeared. 
This  increased  at  first  slowly,  but  at  last  quickly ;  and  when  the  boy 
came  under  my  care,  it  formed  an  oval  swelling  rising  to  nearly  an  inch 
and  a  half  above  the  surrounding  skin,  and  measuring  from  three  to 
three  and  a  half  inches  in  its  diameters.  The  skin  over  it  was  very 
thin,  adherent,  tense,  and  florid,  and  at  the  centre  ulcerated,  and  super- 
ficially scabbed ;  the  ulcerated  surface  was  granulated,  like  one  slowly 
healing.  The  mass  felt  firm  and  elastic,  and,  at  its  borders,  very  tough, 
like  the  tissue  of  a  cicatrix ;  little  cord-like  branching  processes  ex- 
tended from  its  borders  outwards  in  the  deeper  substance  of  the  cutis ; 
and  above  the  principal  mass  another,  like  a  small  flattened  induration 
of  the  skin,  was  felt.  The  growth  was  not  painful,  and  the  general 
health  appeared  good.     Some  axillary  glands  were  slightly  enlarged. 

I  removed  the  whole  disease,  with  all  the  surrounding  skin  that  ap- 
peared in  any  way  unhealthy,  and  large  portions  of  the  fascia  of  the 
fore-arm  and  of  the  intermuscular  septa,  to  which  the  base  of  the  growth 
adhered  intimately,  and  which  were  indurated  and  thickened.  The 
wound  very  slowly  healed ;  the  enlargement  of  the  axillary  glands  sub- 
sided ;  and  the  patient  remains  well  to  this  time,  twelve  years  since  the 
operation. 

The  tumor  was  intimately  adherent  to  all  the  parts  adjacent  to  it, 
yet  was  distinct  and  separable  from  them.  Its  section  was  smooth  and 
shining,  of  stone-gray  color,  shaded  with  yellowish  tints.  It  was  lobed  ; 
but  in  its  several  lobes  was  uniform,  and  with  no  appearance  of  fibrous 
or  other  structure  ;  but  intersected  irregularly  by  white  and  bufi"-yellow 
branching  lines,  where  the  microscope  found  a  fatty  degeneration  of  the 
tissue.  In  texture  the  tumor  was  firm,  but  easily  breaking  and  split- 
ting in  layers,  shell-like  :  with  the  microscope  it  appeared  to  be  com- 
posed of  two  materials ;  namely,  nuclei,  and  a  sparing  granular  or 
molecular  substance,  in  which  they  were  imbedded.     These,  as  sketched 

in  Fig.  81,  were  so  like  those  re- 
presented by  Dr.  Bennett,  as  to 
leave  little  doubt  of  the  similarity 
of  the  two  cases ;  only  there  was 
here  less  appearance  of  fibrous 
structure,  and  less  of  texture  like 
that  of  the  glands.  The  nuclei 
were,  generally,  of  regular  elon- 
gated oval  shape,  from  yg  oo^li  to 
2oVoth  of  an  inch  in  length,  and 
generally  bi-nucleolated ;  compa- 
ratively few  were  broader,  or  reni- 


Fio;.  81* 


<^ 


^ 


*  Fig.  81,  A,  nuclei;  B,  nucleated  structure  of  the  tumor  described  above.     A,  magnified 
450  times;  B,  about  250  times. 


SCIRRHOUS  OR  HARD  CANCER.  519 

form,  or  irregular.  They  were  very  thickset  in  a  molecular  basis-sub- 
stance, and  in  many  parts  (perhaps  in  all  that  were  not  disturbed)  they 
appeared  as  if  arranged  in  overlaying  double  or  triple  rows,  which 
radiated  to  a  distance  from  some  point,  or  from  some  space  of  round  or 
elongated  oval  form.  These  spaces,  if  they  were  such,  appeared  full  of 
molecular  matter. 

It  would  be  wrong  to  endeavor  to  draw  many  conclusions  from  so 
small  experience  as  yet  exists  on  these  tumors.  I  will  only  express  or 
repeat  my  belief  (which  fully  concurs  with  what  Dr.  Bennett  has  stated) 
that  these  are  examples  of  a  form  of  tumor  different  from  any  others 
yet  classified  ;  and  that  they  will  be  found  most  nearly  related  to  the 
recurring  fibroid  tumors. 


LECTURE    XXX. 

SCIKRHOTJS  OR  HAED  CANCER. 
PART    I. — ANATOMY. 

The  foregoing  lectures  on  tumors  have  comprised  the  histories  of  the 
Innocent  and  the  Recurrent  Tumors  ;  and  in  the  first  of  them  I  re- 
lated the  characters  generally  appertaining  to  the  Malignant  Tumors, 
or  Cancers,  which  it  now  remains  to  describe. 

For  an  account  of  this  class  of  tumors  it  will,  I  hope,  sufiice  if,  after 
reference  to  the  first  of  these  lectures,  I  describe,  in  order,  each  of  the 
chief  forms  in  which  cancers  occur,  and  then  gather  such  conclusions 
as  may  be  drawn  respecting  the  general  pathology  of  the  Avhole  class, 
and  the  relations  of  the  several  forms  to  each  other,  and  to  other 
tumors. 

The  chief  forms  of  cancer  are  named  severally  Scirrhous,  Medullary, 
Epithelial,  Colloid,  Osteoid,  Melanotic,  Villous,  and  Hsematoid.  These, 
at  least,  are  the  names  most  frequently  applied  to  them.  The  degrees 
of  difference  between  the  diseases  to  which  they  are  severally  applied 
are  not  nearly  equal ;  and,  probably,  under  certain  of  them,  two  or  more 
diseases  are  included  which  are  sufficiently  different  to  justify  their 
separation  with  distinct  names.  But  these  are  points  which,  having  just 
mentioned,  I  may  leave  to  be  discussed  in  the  account  of  each  form  of 
cancer,  or  in  the  concluding  lectures. 

First,  I  will  speak  of  Scirrhous  or  Hard  Cancer. 

Being  both  more  frequent  and  more  obvious  than  any  other  form  of 
cancer,  this  was,  to  the  beginning  of  the  present  century,  the  type  and 
chief  example  of  the  disease ;  and  so,  in  regard  to  its  physiology,  and 
many  particulars  of  its  structure,  it  may  still  remain.     It  has  received 


520  HAED  CANCER  OF  THE  BREAST. 

many  names,*  such  as  scirrhus,  scirrhoma,  and  others,  expressing  that 
hardness  of  texture  which  is  its  distinctive  and  especial  character- 
istic ;  or  such  as  Carcinoma  reticulare,  implying  certain  minute  pecu- 
liarities of  structure.  I  believe,  however,  that  these  peculiarities  are 
too  inconstant  and  accidental  to  justify  the  division  that  they  suggest : 
I  will  therefore  include  them  all  under  the  name  of  Scirrhous  or  Hard 
Cancer  ;  and  will  use  these  terms  for  all  stages  of  the  disease,  avoiding 
that  which  seems  always  a  confusing  distinction  in  which,  before  ulcer- 
ation, the  disease  is  called  Scirrhus,  and  after  it.  Cancer. 

I  will  describe  the  Scirrhous  Cancer,  first,  as  it  occurs  in  the  breast, 
because  here  the  disease  is  far  more  frequent  than  in  any  other  part, 
and  presents,  openly,  most  of  its  varieties  of  appearance  according  to 
its  successive  stages,  and  the  accidents  to  which  it  is  exposed. 

The  scirrhous  or  hard  cancers  in  the  breast  are  very  far  from  being 
so  uniform  that  they  may  be  briefly  described.  I  believe  that  they  are 
always  primary  cancers ;  ahyays  infiltrations ;  and  almost  always 
seated,  in  the  first  instance,  in  some  part  of  the  mammary  gland ;  but, 
when  we  compare  their  other  characters  in  any  large  number  of  speci- 
mens, we  find  in  them  many  and  great  diversities.  Probably,  therefore, 
it  will  be  best  if  I  describe  first  and  chiefly  the  ordinary  characters  of 
the  disease ;  the  form  in  which  it  is  most  frequently  seen,  when  it  has 
not  been  changed  by  softening,  ulceration,  or  any  other  morbid  process. 
I  can  then  add  to  this  desci'iption,  by  way  of  comparison,  some  accounts 
of  the  principal  deviations  from  the  more  usual  form ;  and,  in  the  next 
part  of  the  lecture,  can  give  the  history  of  the  changes  that  ensue  in 
the  progress  of  hard  cancers  towards  destruction,  or  in  their  much  rarer 
regress. 

Most  frequently,  the  scirrhous  cancer  of  the  breast  appears  as  a  hard 
mass  occupying  the  place  of  the  mammary  gland,  or  of  some  portion  of 
it.  In  the  cases  I  have  collected  it  has  not  been  more  frequent  in  one 
breast  than  in  the  other.  It  is  least  frequent  at  or  near  the  inner 
margin  of  the  mammary  gland ;  but  with  this  reservation,  it  is  not 
more  frequent  in  one  than  in  another  part  of  the  gland,  or  in  any  part 
than  in  the  whole. 

While  part  of  the  gland  is  cancerous,  the  rest  is,  commonly,  healthy  ; 
but,  according  to  the  age  and  condition  of  the  patient,  it  may  be  more 
or  less  atrophied  and  withered ;  or  excess  of  fat  may  be  accumulated 
around  it ;  or  it  may  contain  numerous  small  cysts,  or  one  or  more 
large  cysts,  most  confusing  to  the  diagnosis ;  or,  more  rarely,  it  may 
be  the  seat  of  mammary  glandular  tumor  (p.  491),  or  of  some  morbid 
change  of  structure.  As  yet,  however,  I  believe,  no  connection  can  be 
traced  between  any  of  these  conditions  and  the  growth  of  cancer,  un- 

*  Enumerated  by  Dr.  Walshe  :  On  Cancer,  p.  10. 


HARD  CANCER  OF  THE  BREAST.  521 

less  it  be  that  it  is  peculiarly  apt  to  happen  in  breasts  that  are  being 
defectively  nourished. 

The  hardness  of  the  cancer,  as  compared  with  that  of  other  tumors, 
is  in  most  cases  extreme :  it  is  about  equal  to  that  of  a  lump  of  fibrous 
cartilage,  and  is  associated  with  a  corresponding  rigidity,  weight,  and 
inelasticity.  Cases,  however,  are  not  unfrequent,  especially  when  the 
cancer  grows  quickly,  in  which  the  mass  is  less  hard, — very  firm  rather 
than  hard, — about  as  flexible  and  elastic  as  the  body  of  an  unimpreg- 
nated  uterus. 

The  size  of  a  hard  cancer  is  seldom  very  great.  In  most  cases,  it  is 
rather  smaller  than  the  part  of  the  gland  which  it  occupies  was  in  the 
healthy  state ;  so  that,  e.  g.,  if  half  a  mammary  gland  become  cancer- 
ous, and  half  remain  healthy,  the  latter  may  be  two  or  three  times 
larger  than  the  former ;  or,  if  the  whole  gland  become  cancerous,  it 
may  be  reduced  to  less  than  half  its  natural  size.  The  exceptions  to 
this  diminution  in  the  size  of  the  cancerous  gland  are,  I  believe,  in  cases 
of  very  rapid  growth,  in  which  the  cancer-material  seems  to  be  added 
more  rapidly  than  the  materials  of  the  gland  can  be  removed. 

The  shape  of  the  hard  cancer,  also,  depends  chiefly  on  the  part  of  the 
gland  that  it  afi"ects.  Generally,  it  may  be  said  that  when  the  cancer 
does  not  extend  beyond  the  limits  of  the  gland,  it  does  not  much  deviate 
from  the  shape  of  the  afiected  part ;  only,  it  gathers  up,  as  it  were,  the 
gland-lobes  into  an  irregular  lump,  in  which  their  outline  is  not  lost, 
but  blunted.  Hence,  according  to  their  seats,  we  may  observe  different 
shapes  of  hard  cancers  of  the  breast.  At  the  anterior  surface  of  the 
gland  it  is  usually  convex  or  obliquely  shelving ;  at  the  posterior  sur- 
face it  is  flat  or  slightly  concave,  resting  on  the  pectoral  muscle ;  in 
the  middle,  or  thick  sub-  -p.     gg  * 

stance,  of  the  gland  it  is 
commonly  rounded  and 
coarsely  tuberous,  knot- 
ted, or  branched ;  at  the 
borders  it  is  often  discoid, 
or  else  is  peculiarly  apt  to 
extend  from  them  in  a 
mass  reaching  to  the  ad- 
jacent skin  (Fig.  82) ;  and 
when  the  whole  gland  is 
affected,  the  cancer  has  commonly  a  low  conical  shape,  or  is  limpet- 
shaped,  with  the  nipple  set  on  the  top  of  the  cone  (Fig.  83). f 

*  Fig.  82.  Section  of  a  hard  cancer,  extending  from  a  border-lobe  of  the  mammary 
gland  to  the  superjacent  skin,  and  affecting  both  these  and  the  intervening  tissues.  Natu- 
ral size. 

f  The  terms  "  ramose,"  "  tuberous,"  and  "  infihrated,"  have  been  applied  to  specify  the 
hard  cancers,  according  to  their  shapes ;  but  at  present  the  shape  appears  so  little  connected 
with  any  other  character  of  the  disease, — it  seems  so  nearly  accidental, — that  it  cannot  well 

34 


522      ANATOMY   OP    SCIRRHOUS    CANCER    OF    THE    BREAST. 

From  any  such  cancerous  lump,  processes,  like  crooked,  gnarled, 
and  knotted  branches,  may  extend  outwards  in  correspondence  with 
the  outlying  lobes  or  processes  of  the  gland.     But  shapes  like  these  are 

comparatively  rare  ;  and 
■^^S-  83.*  scarcely   less   so  are  the 

instances   in    which    por- 
tions of  the  gland,  after 

-     ,,.,-.  _,_  ^^~ -^ ^       becoming  cancerous,    are 

<^«s^, ..'  .  •■-     ;    ^s^^^^HT  ■•• ■i.^S  &""^.  J     detached  from   the   chief 

mass  ;  or  those  in  which, 

in  the  same  gland,  more 

than  one  cancer  forms  at 

the  same  time.     Such  cases  do,  however,  happen;   and  I  have  known 

the  smaller  detached  cancers  nearly  escape  removal  in  operations. 

As  we  dissect  towards  the  surface  of  a  hard  cancer,  especially  of  one 
of  which  the  growth  is  not  very  rapid,  we  may  observe  that  relation  of 
the  tissues  around  it  which  is  so  characteristic :  I  mean,  their  contrac- 
tion towards  it,  and  their  progressive  absorption.  It  is  as  if,  in  its  pro- 
gress, the  cancer  were  always  growing  and  more  dense,  by  the  contraction 
and  compacting  of  its  substance,  and  by  the  absorption  of  the  tissues  it 
involves ;  and  as  if,  in  this  concentric  contraction,  it  drew  all  parts 
towards  itself.  To  this  it  is  due,  that,  even  from  the  first,  and  when 
it  is  yet  very  small,  a  hard  cancer  in  the  breast  feels  as  if  it  could  only 
be  moved  with  the  gland  around  it ;  it  does  not  slide  or  roll  under  the 
finger  as  a  mammary  glandular  tumor  does.  To  this,  also,  is  due  the 
slight  dimpling  of  the  skin  overfthe  nearest  adjacent  part  of  the  can- 
cer, even  long  before  the  two  have  become  adherent ;  and  to  this  we 
must  ascribe  the  more  numerous  depressions,  seaming  and  wrinkling 
the  surface  of  the  breast,  and  making  it  appear  lobed,  when,  in  a  case 
of  cancer  occupying  the  whole  of  a  large  and  fat  breast,  many  parts  of 
the  skin  are  drawn  inwards.  To  the  continuance  of  this  contraction 
and  absorption,  also,  are  due  the  sinking  down  of  the  retracted  nipple, 
and  the  uplifting  of  the  superficial  fibres  of  the  great  pectoral  muscle  ; 
and  then,  the  deeper  furrowing  and  the  adhesion  of  the  sunken  skin  or 
nipple,  and  the  firm  conjunction  of  the  pectoral  muscle  with  the  deepest 
portion  of  the  cancer. 

Sometimes  one  finds  bands  of  tough  tissue  extending  from  the  re- 
tracted parts  of  the  skin  to  the  surface  of  the  cancer.  These  are  com- 
monly supposed  to  be  always  cancerous, — "claws,"  or  outrunners  from 
the  cancer ;  but  the  supposition  is  only  sometimes  true ;  they  often  con- 
sist of  only  the  connective  tissue  between  the  lobes  of  the  subcutaneous 
fat,  condensed  and  hardened. 


be  adopted  for  a  ground  of  specific  appellation.  Moreover,  there  is  no  reason  for  especially 
calling  the  cancers  that  affect  the  whole  gland,  infiltrated ;  for  all  the  hard  cancers  of  the 
breast  are  infiltrations  in  less  or  more  of  its  structure. 

*  Fig.  83.     Section  of  a  hard  cancer  of  a  whole  mammary  gland.     Half  the  natural  size. 


CONDITION    OF    THE     TISSUES    INVOLVED.  523 

A  scirrhous  cancer  in  the  breast  has  no  "distinct  or  separable  capsule 
of  connective  tissue  investing  it :  the  proper  tissues  of  the  breast,  that 
are  in  contact  with  its  surface,  adhere  to  it  very  intimately ;  and  the 
more  so,  the  more  slowly  it  has  grown.  The  general  boundary  be- 
tween them  is,  indeed,  distinct  to  the  sight ;  yet  it  is  not  easy  to  dis- 
sect out  the  cancer  ;  and,  at  certain  parts,  it  is  evident  that  the  tissues 
around  the  cancer  are  continuous  with  some  of  those  within  it.  Espe- 
cially, we  can  often  see  that  the  lactiferous  ducts  pass,  from  the  nipple, 
or  some  healthy  portion  of  the  gland,  right  into  the  substance  of  the 
cancer. 

When  we  cut  through  an  ordinary  hard  cancer  of  the  breast,  such  as 
I  am  chiefly  describing,  the  surface  of  the  section  becomes  at  once,  or 
in  a  few  minutes,  slightly  concave.  This  is  a  very  characteristic  ap- 
pearance, though  not  a  constant  one  :  I  know  no  other  tumor  that  pre- 
sents it.  In  all  others,  I  think,  the  surface  of  the  section  either  rises, 
and  becomes  slightly  convex,  especially  at  its  borders,  or  remains  ex- 
actly level.  In  well-marked  hard  cancer,  the  cut  surface  becomes  con- 
cave, sinking  in  towards  its  centre,  through  the  persistence,  I  suppose, 
of  that  tendency  to  contraction,  to  which,  during  life,  we  have  to  ascribe 
the  traction  of  the  surrounding  tissues,  and  which  is  now  no  longer  re- 
sisted by  them. 

The  cancer  seldom  appears,  on  its  cut  surface,  divided  into  lobes  :  it 
is  one  mass,  variously  marked,  perhaps,  but  not  partitioned ;  neither 
has  it  any  distinct  grain  or  fibrous  plan  of  structure ;  its  toughness  and 
tenacity  are  complete,  and  in  every  direction  equal.  It  has,  generally, 
a  pale  grayish  color,  and  is  glossy,  and  half  translucent ;  often  it  is 
slightly  tinged  with  a  dim  purple  hue,  or,  in  acute  cases,  may  be  more 
deeply  and  more  darkly  suffused.  Yery  often,  too,  its  grayish  basis  is 
marked  with  brighter  whitish  lines,  like  interlacing  bundles  of  short 
straight  fibres,  and  with  minuter  ochre-yellow  lines,  or  small  yellow 
spots,  and  with  various  transverse  and  oblique  sections  of  ducts. 

The  explanation  of  these  various  appearances,  and  of  the  minuter 
characters  of  the  cancer,  can  be  understood  only  by  recollecting  (what 
all  the  foregoing  description  will  have  implied),  that  the  cancerous  mass 
is  composed  not  only  of  structures  proper  to  the  cancer,  but  of  more  or 
less  of  the  tissues  of  the  mammary  gland,  or  other  parts,  among  w^hich 
the  cancer-structures  are  inserted.  And  the  differences  implied  in  the 
words  "more  or  less,"  may  be  considered  as  explaining  many  of  the 
differences  of  appearances  that  hard  cancers  present. 

The  consideration  of  the  influence  of  cancer-formations  on  the  tis- 
sues that  they  occupy  belongs,  more  properly,  to  the  general  patho- 
logy of  the  disease;  but  I  must  here  just  refer  to  the  main  facts  concern- 
ing it. 

As  I  have  said,  the  formation  of  a  scirrhous  cancer  of  the  breast  con- 
sists in  the  production  of  peculiar  structures — cancer-cells  and  others — 
in  the  interstices  of  the  proper  tissue  of  the  part  (see  Fig.  84,  p.  525). 


524     ANATOMY  OP  SCIRRHOUS  OR  HARD  CANCER. 

Yirchow*  has  fairly  likened  it,  so  far  as  the  relation  of  the  new  and  old 
materials  is  concerned,  to  the  condition  of  pneumonia  in  a  lobule  of  the 
lung,  in  which  the  lymph  is  situated  among  the  natural  textures,  so  as 
to  be  thoroughly  mixed  up  with  them,  and  to  form  one  mass  with  them. 

Thus,  then,  we  have,  in  any  such  cancer  of  the  breast,  a  mixture  of 
cancer-substance  and  breast-substance.  But  among  many  cancers  we 
should  find  many  diversities  in  the  proportions  of  these  two  substances, 
which  diversities  are  determined,  first,  by  the  original  proportions  in 
which  the  two  substances  are  mingled ;  and,  secondly,  by  the  degrees  of 
wasting,  and  other  changes,  that  may  occur  in  either  or  both  of  them. 
For  example,  a  large  quantity  of  cancer-substance  may  occupy  so  small  a 
portion  of  the  gland,  that  this  portion,  spread  out  as  it  is  in  the  substance 
of  the  cancer,  may  be  scarcely  discernible,  and  the  cancer  may  look  like 
a  completely  isolated  tumor ;  or,  on  the  other  hand,  the  whole  of  an  atro- 
phied gland  may  be  condensed  within  a  comparatively  small  cancer. 

Moreover,  after  the  original  proportions  of  the  two  substances  are 
determined,  they  may  not  remain  the  same ;  for  their  subsequent  pro- 
portions of  increase  or  of  decrease  may  be  difi"erent.  Generally,  as  the 
cancer-substance  increases,  so  the  involved  structures  of  the  breast 
diminish  or  become  degenerate,  till  they  can  hardly  be  recognized,  and 
the  cancer  is  where  the  natural  structure  was:  a  complete  "substitu- 
tion," as  M.  Lebert  names  it,  is  thus  accomplished.  But  the  original 
tissues  do  not  thus  disappear  at  any  given  rate,  or  all  in  the  same  rate 
or  order.  The  gland-lobules,  I  think,  waste  very  early :  I  have  never 
found  them  clearly  marked  within  a  hard  cancer.  The  larger  gland- 
ducts  remain  much  longer ;  their  cut  orifices  may  be  often  seen  on  the 
section  of  the  cancer,  or  they  may  be  traced  right  into  it  from  the  nip- 
ple, or  fragments  of  them  may  be  found  in  microscopic  examinations. 
The  small  gland-ducts,  with  their  contents,  often  appear,  in  branching 
bufi"  and  yellow-ochre  lines,  imbedded  in  the  substance  of  the  cancer. 
The  fat  of  the  breast  is  commonly  quickly  wasted ;  we  find  sometimes 
portions  of  it  encircled  by  the  cancer,  and  sometimes  its  yellow  tinge  is 
diflfused  through  parts  of  the  cancer,  as  if  they  were  thoroughly  min- 
gled ;  but  both  these  appearances  are  limited  to  the  superficial  and 
more  lately  formed  portions  of  the  growtji :  they  are  always  lost  in  the 
central  and  older  parts.  There  is  the  same  gradual  disappearance  of 
the  elements  of  the  skin  when  it  is  involved ;  so  that  we  might  say  that 
the  regular  process  in  the  formation  of  a  cancer  of  the  breast  is,  that  as 
the  cancer-substance  increases,  so  the  natural  tissues  involved  by  it  de- 
generate and  waste.  I  repeat,  we  might  say  this,  if  it  were  not  for  the 
fibrous  tissue  that  intervenes  among  the  lobes  and  ducts  of  the  gland ; 
for  this  seems  either  to  waste  more  slowly  than  any  other  part,  or  to 
remain  unchanged,  or  even  in  some  cases  to  increase  with  the  progress 
of  the  cancer.  To  these  conditions  of  the  fibrous  tissue  I  shall  again 
refer. 

*  In  his  Archiv,  B.  i,  p.  95. 


"cancer   juice"   and   "stroma."  525 

Now,  if  to  the  progressive  varieties  that  may  arise,  through  these 
changes  in  the  involved  tissues  of  the  breast,  we  add  that  parts  of  the 
proper  cancer-substance  may  degenerate  or  waste,  or  may  vary  in  their 
method  of  development,  while  other  parts  are  merely  increasing,  we 
may  apprehend,  in  some  measure,  the  meaning  of  those  great  varieties 
of  appearance  which  we  find  in  any  large  series  of  cancers.  They  are 
mainly  due  to  the  different  modes  and  measures  in  which  the  constitu- 
ents of  the  cancer-substance  and  of  the  original  tissues  are,  first,  min- 
gled together,  and  then  increased,  degenerated,  or  absorbed. 

After  this  necessary  explanation,  let  me  return  to  the  description  of 
the  mingled  mass.  We  find,  as  I  have  said,  in  any  ordinary  cancer  of 
the  bre'ast,  a  grayish  basis,  which  contains  the  proper  elements  of  the 
cancer,  but  which  is  or  may  be  intersected  by  visible  fibres,  ducts,  and 
yellow  lines  or  spots,  which  belong  chiefly,  or  entirely,  to  the  textures 
of  the  breast.  One  may  usually  press  or  scrape,  from  the  cut  surface 
of  such  a  cancer,  a  pale  grayish,  thick,  and  turbid  fluid,  which  is  easily 
diffused  through  water,  and  is  much  more  abundantly  yielded  when  the 
cancer  has  been  macerated  for  a  day  or  two  in  water.  It  is  not  creamy, 
but  rather  like  thick  gruel,  and  is  usually  composed  of  a  mixture  of  the 
proper  cancer-substance,  and  of  the  softened  tissues  of  the  breast,  and 
the  contents  of  the  bloodvessels  and  remaining  gland-ducts.  It  is  called 
the  "  cancer  juice,"  and  what  is  left  after  it  is  expressed,  is  called  the 
"stroma"  of  the  cancer  (see,  further,  p.  531).  I  should  state,  how- 
ever, that  about  the  central  and  deeper  parts,  or  sometimes  in  the  whole 
masses  of  the  hardest  cancers,  no  such  fluid  can  be  obtained;  they  yield, 
to  pressure  or  scraping,  only  a  small  quantity  of  yellowish  fluid,  like 
turbid  serum. 

The  remaining  description  of  the  hard  cancer  must  be,  chiefly,  from 
its  microscopic  appearances. 

In  very  thin  sections  it  is  not  difficult  to  see  the  infiltration,  or  inser- 
tion, of  the  cancer-substance  in  the  interstices  of  the  affected  tissues. 
It  may  be  most  clearly  seen  in  sections  of 
any  part  of  the  skin  recently  invaded  by  Fig.  84.* 

the  cancer,  for  here,  in  the  meshes  of  the 
reticulated  connective  tissue,  the  cancer- 
particles  are  quite  distinct,  filling  every  in- 
terval, and  not  obscured  by  the  ddbris  of 
the  gland-ducts  and  their  contents.  I  am 
not  aware  of  any  more  orderly  plan  of  ar- 
rangement of  the  materials  of  the  cancer 
than  that  which  may  be  expressed  by  saying 
that  they  fill  the  interstices  of  whatever 
tissue  they  may  lie  in.     They  may  either 

*  Fig.  84.  Cancer-cells  filling  interstices  among  the  bundles  of  the  connective  tissue,  in 
the  skin  of  a  breast.     Magnified  about  200  times. 


526 


MICROSCOPIC    ANATOMY    OF 


expand  these  interstices,  when  they  accumulate  quickly  and  abundantly, 
or,  when  they  shrivel  and  degenerate,  they  may  allow  the  tissues  to 
collapse  or  contract. 

The  elementary  structures  of  the  cancer-substance,  thus  infiltrated 
in  the  breast,  are  chiefly  two  :  namely  (1),  certain  cells  and  other  cor- 
puscles ;  and  (2)  a  fluid  or  solid  blastema,  or  nearly  homogeneous  sub- 
stance, in  which  these  lie  imbedded.  We  may  study  these,  but,  it  must 
be  admitted,  in  some  confusion  and  uncertainty,  in  the  material  obtained 
by  the  pressure  from  the  cancer. 

The  blastema,  or  intercellular  substance,  presents,  I  believe,  no  pecu- 
liar features.  As  obtained  by  pressure,  it  is  made  very  impure  by  the 
admixture  of  blood  and  other  fluids  ;  and  it  would  be  unsafe  to  describe 
it  more  minutely  than  as  a  pellucid  or  dimly  granular  substance,  which 
in  certain  cases,  yet  I  think  rarely,  assumes  an  appearance  of  fibrous 
texture.  The  corpuscles  of  hard  cancer  are  chiefly  nucleated  cells.  In 
ordinary  cases,  and  where  the  cancer  has  not  been  deflected  from  its 
normal  course,  their  characters- are  constant  and  peculiar,  and  may  be 
described  as  for  the  types  of  "cancer-cells"  (Fig.  85). 

Fiff.  85.* 


In  shape  they  are  various.  Usually  a  large  majority  are  broadly 
oval,  or  nearly  round :  in  some  specimens,  indeed,  all  may  have  these 
forms ;  but,  in  other  specimens,  though  these  prevail,  yet  many  cells 
have  one  or  more  angles,  or  outdrawn  processes,  and  some  are  pyriform, 
some  fusiform,  some  reniform,  some  nearly  lanceolate. 

It  would  be  useless  to  describe  all  the  shapes  that  may  be  found,  for 
we  can,  at  present,  neither  explain  them,  nor  connect  them  with  any 
corresponding  difl'erences  in  the  general  structure  or  history  of  the  can- 
cers in  which  they  severally  occur.  But  we  may  observe,  as  Bruch  and 
others  have  done,  on  this  multiformity  as  a  feature  of  malignant  struc- 
tures :  I  know  no  innocent  tumors,  except  the  cartilaginous,  in  which 
it  is  imitated. 

In  size,  the  hard  cancer-cells  range  from  tbuo^^  ^f  ^^  i^ch  to  ^-^o^^^ 
of  an  inch  in  diameter.  Their  medium  and  most  frequent  sizes  are  from 
yj'ooth  to  y o'ooth !  thc  smaller  dimensions  are  usually  found  in  the  can- 
cers of  quickest  growth. 

In  structure  and  general  aspect  they  most  nearly  resemble,  I  think, 
the  secreting  gland-cells.  Examined  immediately  after  removal,  and 
without  addition  of  water,  they  appear  clear  and  nearly  pellucid ;  but 


*  Fig.  85. 
500  times. 


Cells  and  free  nuclei  of  scirrhous  cancer  :  from  breasts.     Magnified  about 


SCIRRHOUS  OR  HARD  CANCER.  527 

changes  quickly  ensue,  which  water  accelerates,  and  which  hring  them 
to  the  characters  more  generally  ascribed  to  cancer-cells.  They  become 
nebulous,  or  dimly  granular,  or  dotted,  as  if  containing  minute  mole- 
cules; and  they  look  no  longer  quite  colorless,  but  very  lightly  grayish 
or  yellowish.  The  cell-wall  is,  if  it  can  be  seen  at  all,  peculiarly  thin 
and  delicate  :  but  it  is  often  impossible  to  discern  any  ;  and  my  belief 
is,  that  the  cancer-cells  are  often  only  cell-shaped  masses  of  some  soft 
though  tenacious  substance,  within  which  are  nuclei. 

The  nuclei  in  hard  cancers  are  more  constant  in  their  appearances  than 
the  cells,  and,  I  think,  are  even  more  characteristic.  They  are  always 
comparatively  large,  having  an  average  long  diameter  of  about  25'^otli 
of  an  inch,  and  varying  from  this  size  much  less  than  the  cells  do  from 
theirs.  They  are  regular,  oval,  or  nearly  round,  clear,  well-defined, 
scarcely  altered  by  commencing  decomposition,  or  by  water,  or  any 
moderately  diluted  test-substance.  A  single  nucleus  is  usually  con- 
tained in  each  cell ;  two  nuclei  in  a  cell  are  frequently  found,  but  not 
in  all  specimens  of  hard  cancer  ;  more  than  two  are  rare  :  when  more 
than  one  are  found  in  a  cell,  they  are  generally  smaller  than  those  that 
are  single. 

Among  the  materials  of  a  hard  cancer,  a  certain  number  of  free  nuclei 
are  usually  found.  It  may  be  difficult  to  prove  that  these  have  not  es- 
caped from  cells  during  examination  :  but  I  think  they  are  naturally 
free  nuclei ;  for  they  are  often  larger  than  those  contained  in  cells,  and 
they  sometimes  deviate  from  the  common  shape,  after  methods  which 
are  more  often  noticed  among  the  corpuscles  of  medullary  cancers,  and 
which  will  be  more  fully  described  in  the  next  lecture. 

Each  nucleus  has  one,  two,  or  rarely  more,  nucleoli,  which,  like  itself, 
are  large  in  comparison  with  the  ordinary  proportion  between  nucleoli 
and  cells,  and  are  peculiarly  bright  and  well-defined. 

These  seem  to  be  the  normal  elements  of  hard  cancer ;  and  such  as 
we  find  them  in  the  breast,  such  are  they,  but  less  mingled  and  confused 
with  other  forms,  in  the  hard  cancers  of  the  skin,  the  bones,  and  other 
organs.  Indeed,  these  characters  are  so  nearly  constant  and  so  pecu- 
liar, that  an  experienced  microscopist  can  very  rarely  hesitate  in  form- 
ing upon  them  a  diagnosis  of  the  cancerous  nature  of  any  tumor  in  which 
they  are  observed. 

But  it  would  seem  as  if  hard  cancer  seldom  long  maintained  an  un- 
disturbed course;    for  we  seldom  find  these 
structures,  without  finding  also  cells  mingled  ■^^^'  ^^"^ 

with  them,  in  which  degeneration  or  disease 
has  taken  place.  Some  of  them  are  withered 
(Fig.  86) ;  some  contain  minute  oily  particles  ; 
some  are  completely  filled  with  such  parti- 
cles, or  are  transformed  into  granule  masses         ^^^'''^^u^^^ 

*  Fig.  86.  Withered  hard  cancer-cells,  with  debris. 


528 


MICROSCOPIC    ANATOMY    OF 


Fig.  87.* 


(Fig.  87) ;  and  with  these  we  always  find  abundant  molecular  and  gra- 
nular matter,  in  which,  as  in  the  debris  of  cells,  the  nuclei  lie  loose. 
This  debris,  too,  let  me  add,  is  always  increased  when  the  cancer  is 
kept  for  a  day  or  two  before  examination,  and  when  water  acts  upon 
it.  The  loss  of  clearness  by  the  cancer-cell,  of  which  I  have  already 
spoken  (p.  526),  is  only  the  first  of  a  series  of  changes, 
in  the  course  of  which  the  material  of  the  cells  breaks 
up  into  molecular  and  amorphous  debris  :  fragments 
of  it  may  hang  about  the  nuclei ;  but,  finally,  the  cells 
are  completely  disintegrated,  and  the  nuclei,  com- 
paratively unchanged,  are  set  free. 

Among  the  tissues  of  the  breast  itself  which  are  in- 
volved by  the  cancer,  the  gland-lobes,  I  have  already 
said,  are  quickly  removed  ;  but  their  debris  may  con- 
tribute to  the  molecular  matter  which  is  mingled  with 
the  proper  corpuscles  of  the  cancer. 

The  larger  .gland-ducts,  involved  in  the  cancer, 
often  appear  thickened ;  and  their  contents,  which  are 
usually  a  thick,  turbid,  greasy  fluid,  present  abundant 
granule-masses,  withered  cells  like  epithelial  cells  of 
ducts,  fragments  of  membrane,  free  nuclei  shrivelled 
and  deformed,  molecular  and  granular  matter  :  all 
these  being,  I  suppose,  their  natural  contents,  degenerate  and  disinte- 
grated. 

But  the  more  remarkable  and  characteristic  appearances  are  pro- 
duced chiefly  or  in  great  part  by  the  smaller  gland-ducts,  and  the  fibrous 
tissue  inclosed  in  the  cancer.  The  former  chiefly  constitute  that  which 
has  been  named  "  the  reticulum"  of  hard  cancer,  and  which  has  sug- 
gested the  name  of  Carcinoma  reticulare  for  the  specimens  in  which  it 
is  well  seen.f 

The  most  usual  appearances  of  what  is  now  described  as  "  reticu- 
lum" are  two ;  and  these  may  exist  separately,  or  may  coincide.  In 
one,  which  is  the  most  characteristic,  and,  indeed,  the  only  one  to  which 
the  name  can  apply,  we  see  flne,  branching,  and  variously  interlacing 
and  netted  lines,  of  an  opaque-white,  bufi",  or  ochre-yellow  hue.  They 
appear  as  if  formed  of  thickly  sprinkled  dots.  They  traverse  the  very 
substance  of  the  cancer ;  and  it  is  important  to  observe  that  when  the 
cancer  occupies  but  a  small  portion  of  the  mammary  gland,  these  netted 


*  Fig.  87.  Hard  cancer-cells,  showing  the  progress  of  fatty  degeneration. 

■|-  Under  the  name  of  Carcinoma  reticulare,  Mtiller  included  many  cancers  that  could  not 
have  been  scirrhous  or  hard  cancers.  On  this  ground  I  think  the  name  had  better  not  be 
retained;  for,  whatever  the  "  reticulum"  be  formed  by,  it  is  too  accidental  to  be  considered 
a  specific  character,  and  is  associated  with  too  great  diversities  of  other  characters,  to  be  used 
even  arbitrarily,  for  the  determination  of  a  species.  It  is  not  even  confined  to  cancers;  cor- 
responding appearances  may  be  found  in  fibro-cellular,  cartilaginous,  fibro-nucleated,  and 
probably  several  other  lumors  (see  pp.  408,438,  518). 


SCIRRHOUS     OR    HARD     CANCER.  529 

lines  are  found  only  in  that  part  of  it  which  corresponds  with  the  gland- 
substance. 

In  the  other  and  rarer  form  of  what  is  also  called  "reticulum,"  we 
find  larger  dots  or  small  masses  of  ochre-yellow  substance,  such  as  are 
compared  to  seeds.  These  lie  more  widely  scattered  in  the  substance 
of  the  cancer,  and  may  often  be  pressed  from  it,  like  the  comedones,  or 
retained  white  secretion  from  obstructed  hair-follicles. 

I  believe  that  these  yellow  "  seed-like  bodies,"  which  are  apt,  if  we 
examine  them  superficially,  to  be  confounded  with  the  degenerate  con- 
tents of  the  larger  ducts,  are  always  small  portions  of  the  cancer,  degene- 
rated and  softened,  or  partially  dried.  We  find  in  them  abundant 
granule-cells  and  granule-masses,  some  entire,  some  in  fragments  ;  frag- 
ments, also,  of  granular  and  nebulous  blastema  (as  it  seems),  and  often 
of  nucleated  membrane ;  and  these  lie  in  molecular  and  granular  mat- 
ter diffused  in  liquid,  with  minute  oil  drops,  and  often  with  crystals  of 
cholesterine.  But  with  these  products  of  complete  degeneration,  we 
may  commonly  find,  also,  cancer-cells,  of  which  the  great  majority  are 
either  degenerate,  filled  with  fatty  matter,  like  granule-cells,  or  disin- 
tegrated ;  or  else  (when  the  substance  is  drier)  shrivelled  and  dried  up, 
like  the  lymph  and  pus  corpuscles  that  we  may  find  in  chronic  inflamed 
lymphatic  glands  (Figs.  86,  87). 

Similar  to  these  in  their  component  structures  are  the  larger  masses 
of  friable  yellow  substance,  like  tuberculous  deposits,  which  are  rarely 
found  in  hard  cancers,  but  are  very  frequent  in  the  medullary  cancers. 

Now,  these  appearances  of  yellow  spots, — whether  seed-like  or  in 
larger  masses — are  not  exclusively  found  in  the  breast,  or  in  glandular 
structures  :  they  may  be  seen  in  any  hard  cancer,  and  are  yet  more 
frequent  in  soft  cancers  in  all  organs.  But  the  fine  branching  and 
netted  lines  that  compose  the  more  characteristic  reticulum  are  found, 
especially,  in  cancers  of  glandular  organs :  and  in  those  of  the  breast  I 
have  so  often  found,  among  the  products  of  degeneration  in  them,  what 
appeared  to  be  portions  of  withered  ducts  and  epithelium,  that  I  feel 
nearly  sure  that  the  essential  characters  of  this  reticulum,  in  the  scir- 
rhous cancers  of  the  breast,  are  to  be  ascribed  to  the  minuter  lactiferous 
tubes  which,  involved  in  the  cancerous  infiltration,  are  now,  with  their 
contents,  compressed,  degenerate,  and  wasting.* 

Lastly,  respecting  the  connective  tissue,  involved  in  the  cancer,  the  fate 
of  this,  I  have  said,  appears  different  in  different  cases.  We  sometimes 
meet  with  a  cancer  of  the  breast  which,  having  just  involved  the  skin, 
shows  us  the  interlacing  bundles  of  cutaneous  fibres  spread  out  or  ex- 
panded by  the  insertion  of  the  cancer-structures  among  them  (as  in 
Fig.  84).  The  skin  in  such  a  case  appears  thickened,  and  its  section 
is  glossy,  gray,  and  succulent,  like  that  of  hard  cancer,  but  dimly  marked 
with  whitish  fibrous  bands.    In  other  and  more  frequent  cases  the  marks 

■*  We  may  compare  them  with  a  kind  of  black  reticulum  seen  in  cancers  of  the  lungs 
or  bronchial  glands. 


530      APPEARANCES     OF    TISSUES    IN    SCIRRHOUS    CANCERS. 

are  absent ;  and  the  fibrous  and  elastic  tissues  of  the  skin  are  not  to  be 
found  :  we  may  presume  that  they  have  been  absorbed  as  the  cancer- 
structures  increased.  I  think  this  removal  of  the  fibrous  and  elastic 
tissues  is  the  more  frequent  event,  both  in  the  skin  and  in  the  gland ; 
yet  in  some  of  the  hard  cancers,  and  in  the  central  hardest  parts  of 
others,  the  fibrous  tissue  of  the  gland — all  that  which  encompasses  the 
gland-tubes  and  becomes,  proportionally,  so  abundant  when  the  secret- 
ing structures  waste — all  appears  to  be  even  increased  and  condensed 
or  indurated. 

Such  cancers  as  these  have  been  regarded  as  examples  of  a  special 
form,  named  Carcinoma  fibrosum,  and  the  fibrous  tissue  found  in  them 
has  been  commonly  considered  as  a  proper  cancerous  structure,  a  re- 
sult of  the  fibrous  development  of  the  cancerous  blastema.  Now,  I 
shall  have  to  refer  (p.  541)  to  certain  genuine  instances  of  fibrous  hard 
cancer,  as  occurring  especially  in  the  ovaries ;  and  I  would  not  deny 
that  part  of  the  cancerous  material  produced  in  a  breast  may  be  de- 
veloped into  fibrous  tissue ;  but.  I  am  sure  that  in  the  large  majority  of 
cases,  the  fibrous  tissue  which  is  found  in  a  cancer  of  the  breast  is  only 
that  which  belonged  to  the  breast  itself,  and  which,  involved  in  the  can- 
cer, may  now  be  either  wasted  or  increased.  For  the  fibrous  tissue  in 
hard  cancers  of  the  breast  is  not  like  morbid  or  new  tissue,  nor  like  that 
which  is  found  in  really  fibrous  cancers,  but  is  like  the  natural  connec- 
tive tissue,  either  healthy  or  indurated  and  condensed.  It  is  also  gene- 
rally mixed  with  fibres  of  elastic  tissues,  such  as  are  intermingled  wnth 
the  natural  areolar  tissue,  but  never,  I  think,  occur  among  the  proper 
constituents  of  cancer,  and  are  very  rare  in  even  the  more  highly  or- 
ganized of  the  innocent  tumors.  I  may  add,  in  confirmation  of  this 
view  of  the  nature  and  origin  of  the  fibrous  tissue  in  cancers  of  the 
breast,  that  when  hard  cancer  occurs  in  organs  which  have  little  or  no 
fibrous  tissue — such  as  cancellous  bone,  the  bfain,  the  liver,  or  the  lym- 
phatic glands — it  presents  little  or  none  of  the  same  tissue :  however 
hard  it  may  be,  it  is  formed  almost  entirely  of  corpuscles.*  The  dif- 
ference in  this  respect  is  often,  indeed,  very  striking  between  the  hard 
cancer  of  the  breast  and  that  of  the  corresponding  axillary  glands. 
Both  may  be  equally  hard  and  manifestly  identical  in  nature ;  yet,  while 
the  cancer  of  the  breast  may  include  abundant  fibrous  tissue,  that  in 
the  glands  may  have  scarcely  a  trace,  f 

I  have  dwelt  the  more  on  this  point  because  the  current  method  of 

*  See,  respecting  the  hard  cancer  of  the  brain,  a  case  well  described  by  Dr.  Redfern, 
(Monthly  Journ  ,  Dec,  1850).  I  think  all  that  Virchow,  Lebert,  and  some  others  have 
written,  is  quite  consistent  with  this  view,  though  they  seem  to  hesitate  in  accepting  it. 

■j-  If  it  seem  strange  that  in  some  hard  cancers  the  fibrous  tissue  of  the  involved  organ  in- 
creases, while  in  others  it  is  diminished,  the  strangeness  may  be  made  to  seem  less  by  the 
more  glaring  examples  of  difference  among  cancers  of  bones; — from  the  eroding  secondary 
hard  cancers,  in  which  the  osseous  tissue  wholly  disappears,  to  the  medullary  cancers,  in 
■which  the  osseous  tissue  increases  commensurately  with  the  cancer  and  grows  out  into  it  as 
a  spongy  skeleton  or  framework. 


SCIRRHOUS  OR  HARD  CANCER  OF  THE  BREAST.    531 

describing  all  cancers  as  composed  of  a  peculiar  "stroma,"  the  meshes 
of  which  are  filled  by  a  peculiar  "  cancer  juice,"  appears  to  me  very 
deceptive,  and  often  incorrect.  The  expressions,  as  they  are  commonly 
used,  imply  that  the  fibrous  tissue  or  stroma,  and  the  cells  and  other 
materials  which  form  the  juice,  are  alike  proper  and  essential  to  the 
cancer.  But  I  believe  that  in  the  large  majority  of  cancers  of  the 
breast  the  only  "stroma,"  the  only  substance  that  would  remain,  after 
removing  all  that  is  cancerous,  would  be  the  structures  of  the  breast 
itself.  And  so,  in  other  cancers,  my  belief  is,  that  if  we  except  the 
rare  examples  of  the  really  fibrous,  and  osteoid  cancers,  to  which  I 
shall  hereafter  refer,  there  are  few  in  which  more  than  a  very  small 
quantity  of  fibrous  tissue  is  formed. 

In  the  foregoing  description  I  have  had  in  view,  almost  exclusively, 
the  forms  of  hard  cancer  which  are  most  frequent  in  the  breast ;  in- 
stances of  the  ordinary  or  typical  characters  of  the  disease.  But  as  I 
said  at  the  outset,  the  deviations  from  these  medium  forms  are  neither 
few  nor  inconsiderable,  even  though  we  do  not  count  among  them  any 
of  the  varieties  of  appearance  which  are  due  to  degeneration,  or  to 
disease  of  the  cancerous  structure,  or  to  varying  conditions  in  the  parts 
about  the  mammary  gland. 

And,  first,  varieties  appear  which  may  be  referred  to  different  degrees 
of  activity  or  intensity  of  the  disease.  The  examples  which  I  have 
hitherto  chiefly  described  might  hold  a  middle  place  in  a  series  at  the 
opposite  ends  of  which  would  be  those  of  what  have  been  sometimes 
called  the  "acute"  and  the  "chronic"  cancers.* 

The  well-marked  examples  of  the  former  kind  are  distinguished,  not 
only  by  rapid  progress,  but  by  structure.  They  are  scarcely  to  be 
called  hard — they  are,  at  the  most,  firm,  tense,  and  elastic ;  and  they 
may  even,  though  not  morbidly  softened,  present  a  deceptive  feeling  of 
fluctuation.  Their  cut  surfaces  do  not  become  concave ;  they  are  suc- 
culent, and  yield  abundant  fluid  upon  pressure  ;  they  are  often  suffused 
with  vascularity,  especially  about  their  borders.  The  quantity  of  can- 
cer-structure in  them  is  very  large,  in  proportion  to  the  quantity  of 
gland  in  which  it  has  its  seat.  Hence  the  section  of  an  acute  cancer 
appears  more  homogeneous,  and  its  growth  produces  a  manifest  enlarge- 
ment or  swelling,  the  morbid  material  expanding  the  tissues  around  and 
involved  within  it.  The  surrounding  tissues,  also,  are  less  closely  con- 
nected with  the  cancer  than  they  usually  are,  and  it  may  appear  like  a 
distinct  isolated  tumor,  rather  than  an  infiltration. 

In  all  these  cond  itions  the  acute  scirrhous  cancers  approximate  to  the 
characters  of  medullary  cancers ;  and  perhaps  the  expression  is  not 
unjust,  that  they  are  examples  of  an  intermediate  form  of  the  disease. 

*  Most  of  the  acute  forms  are  such  as  some  call  elastic  cancers:  most  of  the  chronic 
would  be  classed  as  fibrous  cancers  by  those  who  adopt  that  term.  "  Hypertrophic"  and 
"  atrophic"  have  also  been  applied  to  them  as  terms  of  contrast. 


532  ACUTE    AND    CHRONIC    CANCEE. 

And  the  approximation  is  shown  in  some  other  characters,  especially  in 
their  more  rapid  growth ;  in  their  usually  affecting  those  whose  mean 
age  is  below  that  of  the  subjects  of  the  harder  and  more  chronic  can- 
cers ;  and  in  the  signs  of  larger  supply  of  blood. 

In  the  chronic  hard  cancers  the  opposites  of  all  these  characters  are 
found.  The  cancerous  mass  is  comparatively  small ;  and,  as  time 
passes,  it  often  seems  to  shrink  and  contract,  rather  than  increase.  It 
is  intensely  hard,  knotted,  and  dry ;  the  adjacent  tissues  appear  tight- 
drawn  to  it,  and  firmly  adherent ;  and  on  its  cut  surface,  which  usually 
appears  deeply  concave,  it  may  show  more  of  the  increased  and  indurated 
fibrous  tissue  of  the  breast  than  of  the  proper  cancer-substance.  All 
the  history  of  the  chronic  cancers  accords  with  these  signs  of  inactivity  : 
they  occur  generally  in  those  that  are  beyond  the  mean  age ;  they  are 
attended  with  no  increase  of  vascularity ;  and  if  the  skin  becomes  in- 
volved in  one,  it  is  only  ruddy  or  palely  livid  at  the  very  seat  of  adhe- 
sion. The  tissues  of  the  breast  itself  usually  appear  to  suffer  a  corre- 
sponding atrophy  ;  the  gland  commonly  shrivels,  and  the  skin  becomes 
lax  and  wrinkled,  or  else  is  filled  out  with  superabundant  fat  accumulating 
around  the  shrinking  gland. 

Either  of  these  forms  of  cancer  may  affect,  in  some  cases,  the  whole 
gland  ;  in  others,  only  a  portion  of  it.  The  characters  of  both  are  most 
marked  when  they  occupy  the  whole  gland,  for  now  the  enlargement 
attending  the  acute  cancer,  and  the  shrinking  that  accompanies  the 
chronic,  are  most  manifest. 

In  general,  the  respective  characters  of  the  acute  and  the  chronic 
cancer  are  consistent  throughout  all  their  course ;  yet  cases  are  not 
rare  in  which  a  scirrhous  cancer  has  shown  all  signs  of  rapid  progress 
at  the  beginning  of  its  career,  but,  after  a  time,  has  inexplicably  re- 
tarded its  course,  and  passed  into  a  chronic  state.  Nor,  on  the  other 
hand,  are  those  rare  in  which  patients  are  seen  dying  quickly,  because 
a  cancer  which  has  been  slowly  and  almost  imperceptibly  progressive  for 
several  years,  at  length  assumes  the  rapidity  and  destructiveness  of  an 
acute  inflammation. 

A  second  series  of  hard  cancers,  deviating  from  the  usual  forms,  con- 
sists of  cases  in  which  the  nipple  and  the  skin  or  other  tissues  of  the 
mammary  gland  are  peculiarly  affected. 

Commonly  the  hard  cancer  extends  from  the  mammary  gland  to  the 
nipple  and  areola,  involving  these  as  it  may  any  other  adjacent  part. 
When  seated  at  or  near  the  centre  of  the  gland,  it  commonly  draws 
down  the  nipple,  which  descends  as  it  were  into  a  round  pit  sunk  below 
the  general  level  of  the  breast.  As  it  extends,  also,  the  cancer-structures 
deposited  in  the  nipple  make  it  hard,  or  very  firm  and  elastic,  inflexible, 
and  comparatively  immovable.  But  the  changes  which  thus  usually 
occur  later,  or  in  a  less  degree  than  those  in  the  gland,  may  commence 
or  predominate  in  the  nipple  or  the  areola.     The  former  may  be  found 


SCIRRHOUS    CANCER     OF    THE    NIPPLE,    AREOLA,    ETC.         533 

quite  hard  and  rigid  ;  or,  in  the  place  of  the  latter,  there  may  be  a  thin 
layer  of  hard  cancerous  substance,  with  a  superficial  ulcer,  like  an 
irregular  excoriation,  while  the  structures  of  the  gland  itself  are  yet 
healthy. 

In  other  cases,  we  find  the  skin  over  and  about  the  mammary  gland 
exceedingly  affected.  In  a  wide  and  constantly,  though  slowly  widen- 
ing area,  the  integuments  become  hard,  thick,  brawny,  and  almost  in- 
flexible. The  surface  of  the  skin  is  generally  florid  or  dusky  with 
congestion  of  blood  ;  and  the  orifices  of  its  follicles  appear  enlarged,  as 
if  one  saw  it  magnified, — it  looks  like  coarse  leather.  The  portion  thus 
affected  has  an  irregular  outline,  beyond  which  cord-like  offshoots  or 
isolated  cancerous  tubercles  are  sometimes  ^een,  like  those  which  are 
common  as  secondary  formations.  The  mammary  gland  itself,  in  such 
cases,  may  be  the  seat  of  any  ordinary  form  of  hard  cancer ;  but  I  think 
that  at  last  it  generally  suffers  atrophy,  becoming,  whether  cancerous 
or  not,  more  and  more  thin  and  dry,  while  the  skin  contracts,  and  is 
drawn  tightly  on  the  bony  walls  of  the  chest,  and  then  becomes  firmly 
fixed  to  them. 

I  might  add  to  the  account  of  these  deviations  from  the  ordinary 
forms  of  cancer  of  the  breast,  notices  of  some  others ;  but  these  may 
sufiice ;  and  if  it  be  remembered  that  each  of  these,  as  well  as  of  the 
more  common  forms,  is  liable  to  change  by  the  various  degenerations 
and  diseases  of  the  cancer,  enough  will  have  been  said  to  illustrate  the 
exceeding  multiformity  in  which  the  disease  presents  itself  in  the  breast. 
Something,  however,  must  be  added  respecting  the  characters  of  scir- 
rhous cancers  in  other  parts  of  the  body  ;  and  from  these  I  will  select 
chiefly  those  parts  in  which  it  has  the  greatest  surgical  interest,  or  has 
received  the  least  attention  from  morbid  anatomists. 

In  the  Lymphatic  Glands,  the  scirrhous  or  hard  cancer  appears 
very  frequently  as  a  secondary  disease  ;  indeed  there  are  few  cases 
in  which  cancerous  patients  reach  their  average  of  life  without  affection 
of  the  glands  connected  with  the  organ  primarily  diseased.  But,  as  a 
primary  disease,  scirrhous  cancer  of  the  lymphatic  glands  is  very  rare  : 
the  cancer  which  most  commonly  appears  first  in  them  is  the  medullary  ; 
especially,  I  think,  that  of  the  firmer  kind.*  A  specimen  is  in  the 
Museum  of  St.  Bartholomew's,f  which  shows  well-marked  scirrhous 
cancer  in  an  inguinal  gland.  The  gland  is  increased  to  an  inch  and  a 
half  in  length,  and,  while  retaining  its  natural  shape,  nearly  the  whole 

*  The  Index  will,  I  hope,  in  some  measure  correct  the  disadvantage,  which  is  here  evi- 
dent, of  separating,  the  accounts  of  the  ditferent  forms  of  cancer  in  the  same  organ.  The 
disadvantage  is,  I  think,  more  than  compensated  by  the  avoidance  of  confusion  in  the  de- 
scriptions of  the  different  forms ;  and  in  the  Index  the  reader  will  find,  under  the  title  of 
each  chief  organ  or  tissue  (so  far  as  they  are  here  described),  the  references  to  all  the  forms 
of  cancer  occurring  in  it. 

f  Series  xxi,  2. 


534  SCIRRHOUS  OR  HARD  CANCER 

of  its  proper  texture  appears  replaced  by  structures  exactly  resembling, 
in  hardness  and  all  other  properties,  the  ordinary  scirrhous  cancer  of 
the  breast.  It  was  removed  by  Mr.  Lawrence  from  a  lady,  who  re- 
mained well  about  three  years  after  the  operation,  and  in  whom  the 
disease  then  recurred  in  another  inguinal  gland,  which  was  also  removed, 
and  presented  the  same  characters.  They  were  equally  marked  in  the 
progress  through  destructive  ulceration  which  ensued  in  a  primary 
scirrhous  cancer  of  the  axillary  glands,  also  observed  by  Mr.  Law- 
rence. I  believe  I  saw  a  third  instance  in  some  inguinal  glands,  which 
formed  an  exceedingly  hard  swelling  in  and  below  the  groin  ;  but  I  had 
no  opportunity  for  minute  examination  of  them.  There  was  no  proba- 
bility, in  any  of  these  cases,  that  any  other  part  was  the  seat  of  cancer 
before,  or  at  the  same  time  with,  the  lymphatic  glands. 

Cases  sometimes  occur  in  which  the  disease  in  the  glands  may  be  so 
nearly  coincident  with  that  in  the  organ  to  which  they  are  related,  that 
we  may  believe  the  gland-cancer  to  be  primary,  though  not  alone.  And 
sometimes  the  disease  in  the  glands  greatly  preponderates  over  that  in 
the  organ,  even  though  its  primary  seat  was  in  the  latter.  A  woman 
60  years  old,  was  some  years  ago  in  St.  Bartholomew's  Hospital,  in 
whose  right  breast  there  was  a  hard  lump,  less  than  a  pea  in  size,  which 
felt  exactly  like  a  hard  cancerous  tumor  imbedded  in  the  gland.  This 
had  existed  unchanging  for  twenty  years  ;  and  in  the  right  axilla  a 
cluster  of  lymphatic  glands  had  been  rapidly  enlarging  for  twelve 
months,  and  now  formed  a  great  mass  so  uniformly  hard,  heavy,  and 
nodular,  as  I  have  never  seen  formed  by  any  glands  but  those  ajQFected 
with  scirrhous  cancer.  The  case  is,  however,  imperfect,  for  the  patient 
would  submit  to  no  operation,  and  there  may  remain  some  doubt  as  to 
the  nature  of  the  small  tumor  in  the  breast. 

All  these,  however,  are  comparatively  rare  events.  The  ordinary 
course  is,  that  after  the  scirrhous  cancer  has  existed  for  a  time  (the 
length  of  which  seems  at  present  quite  uncertain),  in  the  breast  or  any 
other  organ,  the  lymphatic  glands  in  and  near  the  route  from  that  organ 
towards  the  thoracic  duct  become  the  seats  of  similar  disease.  I  shall 
speak  elsewhere  of  the  probable  method  of  this  extension  of  the  cancer 
to  the  glands.  Its  effects  are  shown  in  a  process  which,  in  all  essential 
characters,  imitates  that  preceding  it  in  the  organ  primarily  diseased. 
Usually  the  cancerous  material  is  deposited,  and  its  structures  are 
formed,  in  the  first  instance,  in  separate  portions  of  one  or  more 
glands.  The  separate  formations  appear  as  masses  of  very  firm  and 
hard  whitish  or  grayish  substance,  of  rounded  shapes,  imbedded  in  the 
glands,  and  contrasting  strongly,  as  well  in  texture  as  in  color,  with 
their  healthy  remaining  portions.  But,  as  the  separate  portions  in  each 
gland  enlarge,  they  gradually  coalesce  till  the  whole  natural  structure 
of  the  gland  is  overwhelmed  and  replaced  by  the  cancer.  Similarly, 
the  same  changes  ensuing  at  once  in  many  glands,  they  form  a  large 


IN    LYMPHATIC    GLANDS.  535 

and  still  increasing  cluster,  and  at  length  coalesce  in  one  cancerous 
mass,  in  which  their  several  outlines  can  hardly  be  discerned. 

The  minute  texture  of  the  hard  cancer  of  lymphatic  glands  differs,  I 
believe,  in  nothing  that  is  important  from  that  already  described  in  the 
cancer  of  the  breast.  Only,  in  microscopic  examinations,  we  find  the 
proper  structure  of  the  lymphatics,  in  the  .place  of  those  of  the  mam- 
mary gland,  mingled  with  the  cells  and  other  constituents  of  the  cancer. 
Neither  is  there  any  essential  difference  in  the  mode  of  deposit  of  the 
cancerous  material ;  it  is,  in  both  alike,  an  infiltration,  though  circum- 
scribed. 

Occasionally,  it  is  said  (but  I  have  never  seen  it),  the  secondary  can- 
cer of  the  lymphatic  glands  is  soft  and  medullary,  while  that  of  the 
organ  primarily  diseased  is  scirrhous.  Very  often,  before  becoming 
cancerous,  the  lymphatic  glands  enlarge  without  hardening, — through 
"simple  irritation,"  as  the  expression  is.  From  this  condition  they 
may  subside  after  the  removal  of  the  primary  cancer,  or  when  corre- 
sponding "irritation"  in  it  is  relieved.  But  the  condition,  whatever  it 
may  be,  is  probably  not  one  of  mere  slight  inflammation ;  for  glands 
which  may  have  thus  subsided,  or  which  have  not  been  visibly  affected, 
may  become  the  sole  or  primary  seats  of  recurrent  cancer,  even  two  or 
more  years  after  the  removal  of  the  primary  disease.  There  seems  to 
be  a  peculiar  state  of  liability  to  cancer,  long  retained  in  lymphatic 
glands,  sometimes  testified  by  enlargement,  but  often  not  discernible 
except  in  its  results. 

Scirrhous  Cancer  of  the  Skin  is  another  of  the  affections  commonly 
occurring  secondarily,  yet  sometimes  appearing  as  a  primary  disease. 
Its  occurrence,  w^hen  the  disease  extends  continuously  from  the  mam- 
mary gland,  is  already  described.  In  a  similar  manner  it  may  be  found 
extending  from  lymphatic  glands,  or  any  other  subcutaneous  organ ; 
and  I  have  described  (p.  533)  how  it  sometimes  precedes  and  surpasses 
in  extent  the  scirrhous  cancer  of  the  breast.  But  its  most  frequent 
appearance,  in  connection  with  cancer  of  the  breast,  and  that  which  is 
imitated  when  it  occurs  as  a  primary  disease  in  other  parts  of  the  skin, 
is  in  tubercles  or  rounded  hard  masses. 

Such  tubercles  are  generally  grouped  irregularly,  but  in  constantly 
widening  areas,  about  the  primary  disease  in  the  breast ;  in  other  parts, 
and  as  primary  cancers,  they  may  be  single  or  numerous.  They  are 
almost  incompressibly  hard,  tough,  circumscribed  masses  or  knots ;  they 
are  usually  of  oval,  flat,  or  biconvex  form,  or,  when  large,  are  tuberous 
or  lobed ;  they  are  imbedded,  as  infiltrations  of  cancer-structures,  in 
the  exterior  compact  layer  of  the  cutis.  They  are  generally  equally 
prominent  above,  and  sunken  beneath,  the  level  of  the  surface  of  the 
skin ;  and  this  condition  is  commonly  acquired  as  well  by  those  which 
commence  like  little  prominent  papulse,  as  by  those  which  at  first  ap- 
pear like  knots  just  subcutaneous.     The  skin  covering  them  is  thin, 


536         SCIRRHOUS     OR     HARD     CANCER     OF    THE     MUSCLES. 

tense,  and  shining ;  it  is  usually  of  a  deep  ruddy  pink  color,  tending  to 
purple  or  brownish-red,  or  it  may  seem  tinged  with  brown,  like  a  pig- 
ment mark.  This  change  of  color  extends  a  little  beyond  the  border 
of  the  cancerous  mass,  and  then  quickly  fades  into  the  natural  hue  of 
the  skin.  Such  cancers  are  movable  with,  but  not  in,  the  surrounding 
skin,  and  even  with  it  the  mobility  is  very  limited  when  they  are  large 
and  deep.  They  may  be  found  of  various  sizes;  in  circumscribed 
masses  ranging  from  such  a  size  as  can  just  be  detected  by  the  touch, 
to  a  diameter  of  two  inches ;  or,  when  diffused  in  the  skin,  occupying  it 
in  an  expansion  of  hardly  limited  extent. 

The  minute  structures,  equally  with  the  general  characters,  of  the 
scirrhous  cancers  of  the  skin,  are,  in  everything,  conformed  with  those 
already  described ;  and  the  characters  of  cancer-cells,  and  their  mode 
of  disorderly  insertion  in  the  interstices  of  the  natural  tissues,  are  in  no 
parts  more  distinct.* 

In  general,  I  think,  the  scirrhous  cancers  of  the  skin  have  a  chronic 
course,  not  painful,  nor  soon  ulcerating ;  but,  as  primary  diseases,  they 
are  too  infrequent  for  a  general  history  of  them  to  be  written  at  present. 
I  have  seen  only  four  examples  of  them  independent  of  previous  cancer 
in  other  parts.  In  one  of  these  the  seat  of  disease  was  nearly  the  whole 
skin  of  the  front  of  the  left  side  of  the  chest  of  a  woman  73  years  old; 
in  another,  it  was  in  the  skin  of  the  leg,  in  the  form  of  cancerous  tuber- 
cles about  the  knee,  of  a  woman  set.  65 ;  in  another,  an  elderly  man's 
scalp  had  two  large,  hard,  cancerous  masses  in  it;  in  a  fourth  the 
disease  was  in  the  scrotum  of  a  man  53  years  old ;  but  I  believe  the 
elementary  structures  of  scirrhous  cancer  were  mingled  with  others 
resembling  those  of  the  more  frequent  epithelial  soot-cancer  of  the  same 
part.f 

In  the  Muscles  scirrhous  cancer  is  commonly  associated  with  its 
most  frequent  form  in  the  skin :  that,  namely,  in  which  it  occurs  in 
groups  of,  tubercles  about  the  primary  disease  of  the  breast.  We  may, 
indeed,  draw  a  close  parallel  between  the  secondary  cancers  in  the  skin 
and  muscles  respectively  ;  for  in  both  parts  alike  we  find,  in  some  cases, 

*  In  the  foregoing  account  I  have  not  had  in  view  that  which  is  commonly  called  the 
"cancerous  tubercle  of  the  face,"  and  which  so  often  occurs  as  the  precedent  of  the  destruc- 
tive process  constituting  the  so-called  "  cancerous"  or  "  cancroid  ulcer"  of  the  face  in  old 
persons.  I  have  not  been  able  to  examine  minutely  one  of  these  tubercles  before  ulceration, 
but  all  I  have  seen  of  the  materials  forming  the  base  and  margins  of  the  ulcers  which  follow 
them,  and  all  the  characters  of  their  progress,  make  me  believe  that  no  cancerous  structure, 
whether  scirrhous,  epithelial,  or  any  other,  exists  in  them.  I  shall  revert  to  this  subject  in 
the  lecture  on  Epithelial  Cancer. 

f  This  specimen  is  in  the  Museum  of  St.  Bartholomew's.  Cases  of  cancer  of  the  skin  are 
related  by  Lebert,  Walshe,  and  others,  in  their  appropriate  chapters ;  but  it  is  not  clear  that  any 
of  them  -were  primary  scirrhous  cancers.  Those  which  were  not  epithelial  cancers  appear 
to  have  been  either  medullary,  of  the  firmer  sort,  or  (in  Lebert's  cases)  melanotic.  All  these 
forms  of  cancer  are  more  frequent  in  the  skin,  as  primary  diseases,  than  that  which  I  have 
described :  they  will  all  be  considered  in  the  following  lectures. 


SCIRRHOUS  OR  HARD  CANCERS  IN  THE  BONES.    537 

discrete  cancerous  tubercles,  in  others  extensively  diffused  cancerous 
deposits ;  and  in  the  muscles,  as  in  the  skin,  the  latter  form  occurs  espe- 
cially when  the  disease  extends  continuously ;  the  former  when  it  is 
multiplied  contiguously  to  its  primary  seat. 

I  have  never  seen  a  primary  scirrhous  cancer  in  a  muscle ;  and  only 
once  have  seen  such  a  cancer  forming  a  distinct  isolated  tumor  in  an 
intermuscular  space.  It  may  be  doubted,  indeed,  whether  this  tumor 
were  the  primary  disease;  yet,  because  of  the  exceeding  rarity  of  scir- 
rhous cancers  in  any  other  form  than  that  of  infiltrations  of  the  tex- 
tures of  parts,  it  deserves  mention.  It  was  taken,  after  death,  from  a 
man  54  years  old,  in  whom  it  had  been  observed  for  a  month,  and  who 
died,  exceedingly  emaciated  and  exhausted,  with  similar  disease  in  his 
axillary  and  bronchial  lymphatic  glands,  his  lungs,  muscles,  occipital 
bone,  and  other  parts.  This  tumor  was  about  four  inches  in  length, 
oval,  surrounded  by  a  distinct  capsule  of  connective  tissue,  and  seated 
between  the  brachialis  anticus  and  biceps  muscles,  outspreading  both  of 
them.  It  had  the  same  hardness,  weight,  and  density,  and  the  same 
microscopic  cell-structures,  as  the  ordinary  hard  cancers  of  the  breast ; 
it  was  milk-white,  slightly  suffused  with  pink  and  gray,  and  distantly 
spotted  and  streaked  with  ochre-tints.  The  other  cancerous  masses  had 
for  the  most  part  the  same  characters ;  but  some,  which  by  their  size 
and  positions  might  certainly  be  considered  as  of  latest  production,  were 
soft,  and  like  the  most  frequent  medullary  cancers. 

In  the  Bones,  as  in  the  muscles,  the  scirrhous  cancer  seldom,  if  ever, 
occurs,  except  as  a  secondary  disease  :  the  primary  cancers  of  bones  are, 
I  think,  always  either  medullary,  osteoid,  or  colloid.  The  structures 
of  the  scirrhous  cancer  may  be  infiltrated  or  diffused  among  those  of 
the  bone,  or  they  may  form  distinct  masses  ;  but  in  neither  case  do  they 
so  increase  as  to  form  considerable  tumors.  In  some  of  the  cases  of 
infiltration,  the  cancerous  substance  is  diffused  through  the  cancellous 
tissue  of  the  bone,  while  its  walls  are  comparatively  little  changed :  in 
others  all  the  bony  structures  are  expanded  into  an  irregular  frame- 
work of  plates  and  bands,  the  interstices  of  which  are  filled  with  cancer- 
ous substance,  hard,  elastic,  gray,  and  shining.*  On  the  other  hand, 
when  separable  cancerous  masses  are  formed,  they  are  usually  round  or 
oval,  or  adapted  to  the  shape  of  the  inner  walls  of  the  bone,  within 
which  they  are,  at  least  for  a  time,  confined.  They  generally  appear 
as  if,  while  they  were  growing,  the  original  bony  textures  around 
them   had  gradually  wasted  or   been   absorbed,  making  way  for  their 

*  Nos.  822-3  in  the  College  Museum  are  examples  of  the  first  form  ;  and  No.  5  (Ap- 
pendix) in  that  of  St.  Bartholomew's  may  exemplify  the  second.  The  latter  specimen  was 
taken  from  a  case  in  which  a  cancerous  femur  was  broken  eight  months  before  death,  and 
the  new  bone,  with  which  it  was  repaired,  was  infiltrated  with  cancer  as  well  as  the  ori- 
ginal textures. 

35 


538 


SCIREHOUS    OR    HARD    CANCER 


further  growth.* 
Fig.  884 


m: 


And  thus  the  growth  of  the  hard  cancer,  with  ab- 
sorption (whether  previous  or  consequent)  of  the 
bone  around  it,  may  continue  till  not  only  the 
medullary  tissue,  but  the  whole  thickness  of  the 
wall,  is  removed,  and  the  cancer  may  project 
through  and  expand  beyond  it,  or  may  alone  fill 
the  periosteum,  retaining,  with  very  little  change, 
the  original  shape  and  size  of  the  bone.f 

In  both  these  sets  of  cases  the  cancer-cells  are 
alike,  and  they  form,  without  fibrous  tissue,  a  hard, 
or  very  firm,  elastic,  grayish  substance,  shining, 
and  sometimes  translucent,  sometimes  with  an  ob- 
scure fibrous  appearance.  The  likeness  to  the 
common  hard  cancer  of  the  breast  is  complete,  in 
both  general  and  microscopic  characters ;  and  not 
less  complete  the  contrast  with  the  usual  forms  of 
the  medtillary  cancer,  which,  as  I  have  said,  is  the 
more  frequent  primary  disease  of  the  bones.  In- 
termediate specimens  may,  indeed,  be  found  ;  yet, 
on  the  whole,  the  contrast  between  medullary  and 
scirrhous  cancers  is  as  well  marked  in  the  bones 
as  in  any  other  part.§ 

The  bones  thus  cancerous  become  liable  to  be 
broken  with  very  slight  forces ;  and  to  these  con- 
ditions a  certain  number  of  the  so-called  spontane- 
ous fractures  in  cancerous  patients  maybe  assigned. 
But  some  are  due  to  the  wasting  and  degenerative 
atrophy  which  the  bones  undergo  during  the  pro- 
gress of  cancer,  and  which  seems  to  proceed  to  an 

extreme  more  often  than  it  does  in  any  other  equally  emaciating  and 

cachectic  disease. 


\ 


\ 


The  hard  cancer  of  the  Intestinal  Canal,  exemplified  most  fre- 
quently in  the  upper  part  of  the  rectum,  in  the  sigmoid  flexure  of  the 
colon,  and,  sometimes,  in  a  very  striking  form,  in  the  ileo-caecal  valve, 
appears,  usually,  as  an  infiltration  of  hard  cancer-structures  in  the  sub- 
mucous tissue.     Here  it  is  usually  of  annular  form,  and   occupies  the 

*  See,  respecting  the  occasional  "preparatory  rarefaction"  of  bones,  previous  to  cancerous 
deposits  in  them,  the  excellent  observations  of  Walshe  (p.  555)  and  Virchow  (Archiv,  1, 12f)}. 

t  As  in  Nos.  817-8-9,  in  the  Museum  of  the  College,  and  in  several  specimens  lately 
added  to  that  of  St.  Bartholomew's. 

\  Fig.  88.  Section  of  a  humerus  vi^ith  hard  cancer,  as  described  above.  Mus.  of  St.  Bar- 
tholomevs^'s. 

§  Medullary  cancer  may  appear  as  a  secondary  disease  in  the  bones,  as  well  as  in  any 
other  parts,  after  primary  scirrhous  cancer  in  the  breast.  The  cases  I  have  examined  would 
make  me  think  that  the  scirrhous  cancer  is,  in  these  events,  the  more  frequent:  but  M.  Le 
bert  (Traite  des  Maladies  Cancereuses,  p.  714)  describes  none  but  soft  cancers  as  occurring 
in  the  bones,  whether  primarily  or  secondarily. 


OF    THE    LARGE    INTESTINES. 


539 


whole  circumference  of  the  intestine,  in  a  length  of  from  half  an  inch  to 
an  inch.  The  cancer  may,  at  the  same  time,  or  in  other  instances, 
occur  externally  to  the  muscular  coat,  and  in  this  case  is  usually  not 
annular,  but  in  separate  tubercles,  which,  until  ulceration  ensues,  pro- 
ject with  flattened,  and  sometimes  centrally  depressed,  round  or  oval 
surfaces,  into  the  cavity  of  the  intestine.  Very  rarely  (it  is  said)  it 
may  aff"ect  the  whole  circumference  of  a  large  extent  of  the  rectum,  and 
may  in  the  same  extent  involve  many  adjacent  parts. 

It  sometimes  happens  that  the  hard  cancer  of  the  submucous  tissue 
is  associated  with  growths  of  softer  medullary  cancer  into  the  cavity  of 
the  intestine,  or  with  formations  of  colloid  cancer.     The  mingling  of 
these  forms  is  certainly  more  frequent 
in  the  digestive  canal  than  in  any  other  ^^S-  ^9-* 

part.  But  that  which  is  most  remark- 
able in  the  hard  cancers  of  the  rectum 
(as  an  example  of  those  of  other  por- 
tions of  the  canal),  is  derived  from  the 
tendency  which  the  cancer  has  here,  as 
in  other  parts,  to  contract  and  con- 
dense, and  adhere  to  the  parts  around 
it.  To  this  it  is  due,  that,  when  an  an- 
nular cancer  of  the  rectum  exists  in  the 
submucous  tissue,  even  the  exterior  of 
the  bowel  appears  constricted  :  instead 
of  swelling,  the  bowel  is,  even  exter- 
nally, smaller  at  the  cancer  than  either 
above  or  below  it:  and  the  stricture,  or 
narrowing  of  the  canal,  which  would  be 
trivial  if  it  depended  only  on  the  can- 
cerous thickening  of  the  coats,  is  made  extreme  by  the  contraction  of 
the  coats  around  and  with  the  cancer.  The  same  conditions  which,  in 
hard  cancer  of  the  breast,  produce  retraction  of  the  nipple  and  pucker- 
ing of  the  skin  over  the  morbid  growth,  here  produce  contraction  of  the 
muscular  and  peritoneal  tissues  around  the  growth,  and  a  concentric  in- 
drawing  of  the  growth  itself. 

With  similar  likeness  to  the  hard  cancers  of  the  breast,  those  in  the 
intestine  (in  the  rectum,  for  example)  give  rise  to  close  adhesion  of  the 
tissues  around  them  to  other  adjacent  parts.  Thus  the  cancerous  part 
of  the  rectum  may  be  fixed  to  the  promontory  or  front  surface  of  the 
sacrum  quite  immovably  ;  or  the  colon  may  become  united  to  the  uri- 
nary bladder,  or  to  some  other  portion  of  the  intestinal  canal. 

Many  other  important  facts  in  the  history  of  this  affection  are  con- 
nected with  the  dilatation  and  hypertrophy  of  the  intestine  above  the 


*  Fig.  89.     Hard  cancer  of  the  rectum,  showing  the  constriction  of  the  peritoneal  and 
muscular  coats  around  the  cancer  of  the  submucous  tissue.      Mus.  of  St.  Bartholomew's. 


540  FIBROUS    HARD    CANCERS    IN    THE     OVARIES,     ETC. 

Stricture ;  the  final  paralysis  of  the  dilated  part,  and  the  phenomena  of 
ileus  chiefly  due  thereto,  with  displacement  of  the  diseased  part  by  the 
weight  of  faeces  accumulated  above  it ;  the  occasional  variations  of  the 
degree  of  stricture,  according  to  the  afliux  of  blood  swelling  the  dis- 
eased part,  or  its  ulceration  or  sloughing  decreasing  it,  and  so,  for  a 
time,  widening  the  canal ;  but  these  I  need  only  enumerate,  while  I  can 
refer  to  Rokitansky*  for  ample  accounts  of  them  all. 

The  large  intestine  is,  probably,  next  to  the  mammary  gland  and  the 
stomach,  the  organ  in  which  the  well-marked  scirrhous  cancer  is  most 
frequently  found  as  a  primary  disease.  It  very  rarely,  indeed,  occurs 
secondarily,  except  when  extending  to  the  intestine  continuously  from 
some  adjacent  part ;  and  in  this  case,  as  it  usually  affects,  at  first,  only 
part  of  the  circumference  of  the  intestine,  it  may  become  much  more 
extensive  without  producing  stricture  ;  for  the  unaffected  part  of  the 
wall  may  dilate  so  as  to  compensate,  for  a  time,  for  the  contraction  of 
the  diseased  part.  Moreover,  when  it  is  a  primary  disease,  the  cancer  of 
the  intestine  is  one  of  the  fornls  in  which  the  disease  may  exist  longest 
without  multiplication,  although  often,  even  in  its  early  stages,  it  is  asso- 
ciated with  exceeding,  and  seemingly  disproportionate,  cachexia. 

I  have  spoken  of  the  occurrence  of  fibrous  tissue  in  the  scirrhous 
cancers  of  the  breast,  and  have  said  (p.  530)  that  this  appears  to  be  no 
proper  element  of  the  cancer,  but  the  natural  connective  tissue  of  the 
part  involved  in  the  cancer,  and  often  increased  and  condensed.  If  this 
be  always  so,  and  if,  as  I  have  also  said,  little  or  no  fibrous  tissue  be 
found  in  cancers  affecting  organs  which  naturally  contain  none,  it  will 
follow  that  the  name  Carcinoma  fibrosum  is  not  well  applied  to  any  ex- 
amples of  hard  cancer  described  in  the  foregoing  pages.  Yet  there  are 
cancers  which  contain  not  only  abundant  but  peculiar  fibrous  tissue ; 
and  these  may  well  be  called  "  fibrous  cancers,"  and  may  be  considered 
as  a  distinct  form  or  species,  unless  it  should  appear  that  they  are  always 
associated,  as  secondary  diseases,  with  scirrhous  cancers  of  the  more 
ordinary  structure  ;  so  that  we  may  suppose  that  the  same  material  is, 
in  one  organ,  developed  into  fibrous  tissue;  in  others,  at  the  same  time, 
into  cancer-cells. 

The  most  remarkable  examples  of  hard  cancers  with  fibrous  struc- 
tures, that  I  have  yet  seen,  have  been  in  the  ovaries  of  certain  patients 
with  common  hard  cancer  of  the  breast  or  stomach. f  In  these  cases, 
the  place  of  the  ovary  on  either  or  on  both  sides  is  occupied  by  a  nodu- 
lated mass  of  uniformly  hard,  heavy,  white,  and  fibrous  tissue.  The 
mass  appears  to  be,  generally,  of  oval  form,  and  may  be  three  or  more 
inches  in  diameter :  its  toughness  exceeds  that  of  even  the  firmest 
fibrous  tumors ;    and  its  component  fibres,   though  too  slender  to  be 

*  Pathologische  Anatomie,  III,  276  and  282. 

f  Museum  of  the  College,  Nos.  240,  2636  ;  and  of  St.  Bartholomew's,  xxxi,  17,  and,  pro- 
bably, xxxii,  14. 


SCIRRHOUS  OR  HARD  CANCER.  541 

measured,  are  peculiarly  hard,  compact,  closely  and  irregularly  woven : 
they  are  not  undulating,  but,  when  they  can  be  separated  singly  or  in 
bundles,  they  appear  dark-edged,  short,  and  irregularly  netted.  With 
these  I  have  found  only  few  and  imperfect  cancer-cells ;  with  more  nu- 
merous nuclei,  elongated  and  slender.  They  are  not  mingled  with  elas- 
tic or  other  "yellow  element"  fibres. 

But  fibrous  cancers  are  not  found  in  the  ovaries  alone.  Peculiar 
stiff-fibred  tissue  is  sometimes  contained,  together  with  less  abundant 
cancer-cells,  in  the  harder  cancers  connected  with  periosteum.  So  I 
have  seen  it  in  the  pelvis,  and  in  the  unossified  parts  of  osteoid  cancers, 
where  neither  its  relations  nor  its  minute  texture  were  such  as  to  sug- 
gest that  it  was  morbidly  increased  periosteum.  However,  the  occa- 
sions that  I  have  had  of  examining  truly  fibrous  cancers  have  been  too 
few  to  justify  any  conclusion  respecting  the  propriety  of  separating 
them,  as'  a  distinct  form,  from  the  scirrhous  cancers.  And  I  cannot 
complete  my  own  imperfect  observations  with  the  records  of  other  pa- 
thologists ;  for  I  think  that  none  have  endeavored  sufiiciently  to  dis- 
criminate between  the  two  kinds  of  fibrous  tissue  that  may  be  found  in 
cancers  ;  namely,  that  which  is  developed  during  the  growth  of  the  can- 
cer, and  that  which  is  derived  from  the  original  fibrous  tissue  of  the 
affected  organ,  whether  in  its  natural  state,  or  increased,  condensed, 
indurated,  or  otherwise  morbidly  changed.  Yet  the  distinction  is  an 
essential  one  ;  for  the  former  is  truly  cancer-structure,  the  latter  is  only 
the  structure  in  the  interstices  of  which  the  cancer  has  its  seat.  A  simi- 
lar distinction  will  have  to  be  made,  in  a  future  lecture,  between  the 
osseous  tissue  that  grows  so  as  to  form  the  framework,  or  interior 
skeleton,  of  certain  medullary  cancers  of  bone,  and  that  which  is  the 
chief  constituent  of  osteoid  cancers  :  the  one  is  a  morbid  growth  of  a 
bone  affected  with  cancer ;  the  other  is  the  proper  cancer-structure 
ossified. 


LECTURE    XXX. 

SCIEKHOUS  OR  HAED  CANCEE. 
PART  II. PATHOLOGY. 

The  former  part  of  this  lecture  being  devoted  to  an  account  of  the 
sti'uctures  of  the  chief  examples  of  hard  or  scirrhous  cancers,  I  propose, 
in  this  second  part,  to  consider  their  history,  their  mode  of  life,  their 
pathology  as  contrasted  with  their  anatomy.  And  here,  even  more 
nearly  than  in  the  former  part,  I  will  limit  myself  to  the  histories  of 
those  of  the  breast ;  for  concerning  the  primary  hard  cancers  of  other 
parts,  we  have  too  few  data  for  any  general  history. 


542 


INFLUENCE    OF    AGE    AND    SEX. 


First,  concerning  the  conditions  favorable  to  the  origin  of  these  scir- 
rhous cancers ; 

(a)  They  exist,  in  great  preponderance,  in   women.     Probably,  of 
every  100  cases  of  scirrhous  cancer  of  the  breast,  98  occur  in  women ;  d 
and,  I  believe,  it  is  chiefly  this  that  makes  cancer,  on  the  whole,  more 
frequent  in  women  than  in  men,  for  in  nearly  every  other  organ  common 
to  both  sexes  the  greatest  frequency  is,  I  think,  found  in  men. 

[b]  The  age  of  most  frequent  occurrence  of  scirrhous  cancer  of  the 
breast  is  between  45  and  50  years.  Nearly  all  records,  I  think,  agree 
in  this.  The  disease  has  been  seen  before  puberty ;  but  it  is  extremely 
rare  at  any  age  under  25  ;  after  this  age  it  increases  to  between  45  and 
50  ;  and  then  decreases  in  frequency,  but  at  no  later  age  becomes  so 
infrequent  as  it  is  before  20. 

The  following  table,  drawn  from  the  records  of  158  cases,  of  which 
the  diagnosis  cannot  be  reasonably  questioned,  will  illustrate  the  fore- 
going statement:* 

2  cases  were  first  observed  between  20  and  25  years  of  age. 

4 

9 
26 
33 

do 

17 

11 

9 

"  above 


25 

"  30 

30 

"  35 

35 

"  40 

40 

«  45 

45 

«  50 

50 

"  55 

55 

"  60 

60 

"  70 

70 

"  80 

158- 


In  another  series  of  276  cases  observed  by  myself,  the  numbers  were : 


Between  20  and  30  years  of  age, 


30 

'  40 

40 

'  50 

50 

'  60 

60 

'  70 

70 

'  80 

5 

41 

122 

65 

35 


These  numbers  may  represent  the  absolute  frequencies  of  the  occur- 
rence of  hard  cancer  of  the  breast  at  different  ages.  But  it  is  more 
important  to  know  the  relative  frequencies  in  proportion  to  the  number 


*  This  and  many  of  the  following  tables  are  drawn  from  a  general  table  of  365  cases  of 
cancers  of  all  kinds.  Of  the  whole  number  nearly  half  were  observed  by  myself  Of  the 
remainder  I  have  derived  about  50  from  the  records  of  the  Cancer  wards  of  the  Middlesex 
Hospital,  for  access  to  which  I  am  much  indebted  to  the  surgeons  of  the  hospital :  more  than 
60  were  very  kindly  communicated  to  me  by  Dr.  Humphry;  others  I  owe  to  Mr.  Lowe  and 
Dr.  Paget :  nearly  all  the  rest  were  collected  from  the  works  of  Wardrop,  LangstafT,  Baring, 
Bruch,  Bennett,  and  Sedillot.  The  ages  assigned  in  this  table  are  those  at  which,  in  each 
case,  the  disease  was  first  observed  by  the  patient ;  and  no  case  is  included  which  was  re- 
corded only,  or  chiefly,  because  it  was  an  example  of  the  disease  occurring  at  an  unusual 
period  of  life. 


SCIERHOUS    CANCER.  543 

of  women  living  at  each  of  the  successive  periods  of  life.  To  ascertain 
this  I  have  added  to  the  cases  in  the  first  preceding  table  those  tabu- 
lated, in  a  nearly  similar  manner,  by  Mr.  Birkett*  and  M.  Lebert  ;t 
making  a  total  of  354  cases  originating  between  the  ages  of  20  and  80 
years.  Then,  comparing  the  number  of  cases  in  each  decennial  period 
of  life,  with  the  number  of  women  alive  in  the  same  period  in  England 
and  Wales  (according  to  the  Population  Returns  for  1841),  it  appears 
that  the  comparative  frequencies,  relatively  to  the  whole  number  of 
women,  may  be  stated  in  the  following  numbers : 

Relative  frequency  of  the 
Ages.  origin  of  hard  cancer. 

20  to  30 6 

30  "  40 40 

40  «  50 .100 

50  "  60 76 

60  "  70 38 

70  «  80 32 

In  other  words,  the  proportions  between  these  numbers  may  repre- 
sent the  degrees  in  which  the  conditions  of  women's  lives,  at  the  succes- 
sive decennial  periods,  are  favorable  to  the  first  growth  of  hard  cancer 
in  the  breast. 

One  is  naturally  led  to  suppose  that  the  great  liability  to  cancer  of 
the  breast  between  40  and  50  years  of  age,  and,  especially,  the  maxi- 
mum between  45  and  50,  are  connected  with  some  of  the  natural  events 
that  are  then  occurring  in  the  n^rly  related  reproductive  organs  ;  such 
as  the  cessation  of  the  menstrual  discharge,  and  of  the  maturation  of 
ova ;  or  else  with  the  wasting  and  degeneracy  of  the  mammary  glands. 
And  yet  it  is  difficult  to  prove  such  a  connection  with  any  single  event 
of  the  period. 

The  event  which  is  generally  regarded  as  most  important  is  the  ces- 
sation of  the  menstrual  discharge.  But  I  find  that  among  52  women 
with  scirrhous  cancer  of  the  breast,  in  whose  cases  this  point  is  noted, 
2T  were  still  menstruating  for  at  least  a  year  after  their  discovery  of  the 
cancer,  and  16  had  ceased  to  menstruate  for  a  year  or  more  previous 
to  it ;  so  that  less  than  one-sixth  of  the  whole  number  afforded  examples 
of  the  cessation  of  the  catamenia  and  the  discovery  of  the  cancer  occur- 
ring within  the  same  year. 

The  following  table  shows  the  ages  at  which  menstruation  ceased  in 
400  women,!  and  the  ages  at  which  hard  cancer  of  the  breast  was  first 
detected  by  an  equal  number  : 

*  On  Diseases  of  the  Breast,  p.  218. 

I  Des  Maladies  Cancereuses,  p.  354.  The  particulars  of  both  these  tables  accord  very 
nearly  with  those  given  above;  but  the  numbers  of  cases  below  20  and  above  80,  in  Mr. 
Birkett's  table,  are  very  large ;  probably  because  he  has  included  cases  that  were  recorded 
on  account  of  their  rarity  in  respect  of  the  patients'  ages. 

J  From  Dr.  Guy's  tables,  in  the  Medical  Times,  1845.  The  numbers  in  the  third  column 
are  obtained  by  doubling  those  in  a  table  of  200  cases,  collected  from  those  of  M.  Lebert  aud 
Mr.  Birkett,  as  well  as  from  my  own. 


544 


SCIRRHOUS     CANCER    OF    THE    BREAST. 


Cessation  of 

First  observatio 

Ages. 

menstruation. 

of  tlie  cancer. 

Below  35 

9             .         . 

36 

35    to  40 

.51              .         . 

62 

40     "    45 

140 

78 

45     "    50 

159 

101 

Above  50 

41 

.      ' .         123 

400 


400 


All  these  calculations  are  sufficient  to  prove  the  great  influence  which 
the  events  of  life,  at  and  about  the  time  of  the  cessation  of  the  men- 
strual process,  exercise  in  the  production  of  the  cancer ;  but  thej  do 
not  prove  that  the  defect  of  that  process  has  more  influence  than  others 
of  the  coincident  events.  This  is  confirmed  by  the  observation  that  in 
75  cases  of  cancer  of  the  breast,  commencing  between  the  ages  of  40 
and  55,  the  disease  began  in  48  before  the  cessation  of  the  catamenia ; 
12  about  the  time  of  their  cessation ;  15  after  it.*  I  think  we  may 
most  safely  hold  that  the  aptness  of  this  time  of  life  for  the  develop- 
ment of  hard  cancer  is  chiefly  due  to  the  general  failure  of  the  process 
of  maintenance  by  nutrition,  which  usually  has  at  this  time  its  begin- 
ning, and  of  which  the  most  obvious  natural  signs  are  in  the  diminution 
of  the  powers  of  the  reproductive  organs.  It  is  in  favor  of  this  view, 
rather  than  of  any  especial  influence  of  the  reproductive  organs,  or  of 
change  in  the  mammary  gland,  that,  so  far  as  we  can  estimate,  with  so 
small  a  number  of  cases  as  are  yet  om  record,  the  ages  of  increasing 
frequency  of  hard  cancer  in  the  male  breast,t  and  of  primary  hard  can- 
cer in  other  organs,  coincide  with  the  results  of  the  far  more  numerous 
cases  in  the  female  breast. 

This  would  hardly  be  so  if  it  were  the  condition  of  the  female  breast 
itself,  or  of  any  nearly  related  organ,  that  alone  or  chiefly  determined 
the  greater  frequency  of  the  cancer  at  particular  periods  of  life. 

{c)  To  these  conditions  of  sex  and  age,  as  favoring  the  production  of 
scirrhous  cancer,  we  may  add  an  hereditary  disposition,  and  the  eftects 
produced  by  injury  or  previous  disease.  The  influence  of  these  condi- 
tions is  not  generally,  but  is  often  very  clearly  manifested.  In  88 
patients  with  hard  cancer  (including  four  men  and  four  cases  of  hard 
cancer  of  other  organs  than  the  breast)  16  were  aware  of  cancer  having 
occurred  in  other  members  of  their  families. 

In  40  tabulated  by  M.  Lebert,  only  6  could  be  deemed  hereditary.^ 

*  Contribution  to  tlie  Statistics  of  Cancer,  by  Mr.  W.  M.  Baker,  Med.-Chir.  Trans.,  vol. 
xlv,  1S62. 

I  The  four  men  in  whom  I  have  seen  hard  cancer  of  the  breast  were  respectively  40,44, 
48,  and  52  years  old  at  the  discovery  of  the  disease. 

X  The  difference  in  the  proportions  of  M.  Lebert's  cases  and  in  mine  is  probably  due  to 
my  having  reckoned  as  hereditary  three  cases  in  which  members  of  the  patients'  families 
had  had  cancers  of  the  lip.  These  would  be  excluded  as  only  "cancroid"  by  M.  Lebert; 
and  so  excluded,  and  added  to  the  non-hereditary  cases,  they  make  the  proportions  very 
nearly  equal  in  both  our  estimates. 


CONDITIONS  OF  GENERAL  HEALTH,  545 

Probably,  therefore,  not  more  than  1  in  6  patients  with  hard  cancer 
can  be  reckoned  as  having  hereditary  tendency  thereto.* 

The  occurrence  of  hard  cancer  in  many  members  of  a  family  cannot, 
then,  be  deemed  frequent ;  yet  when  it  is  observed,  it  is  often  too  strik- 
ing to  leave  any  doubt  about  the  reality  of  an  hereditary  tendency  to 
the  disease. 

(d)  So,  with  regard  to  the  effects'  of  injury  and  previous  disease,  I 
find  that,  among  91  patients,  only  16,  i.  e.  less  than  one-sixth,  ascribed 
the  hard  cancer  to  injury  or  any  such  local  cause.  The  proportion  is 
so  small  (it  is  less,  even,  than  that  of  the  patients  Avith  other  tumors,  who 
ascribe  them  to  the  same  cause),t  that  we  might  be  disposed  to  deny  the 
influence  of  injury  altogether,  if  its  consequences  were  not,  in  a  few 
cases,  so  manifest  and  speedy. 

(e)  The  influence  of  the  single  and  married  states  is  shown  by  Mr. 
Baker  (1.  c.)  in  a  table  of  260  cases  of  cancer  of  the  breast,  in  which 
the  proportions  were : 

Single, 23.0  per  cent. 

Married, 72.4       •' 

Widow, 4.6       " 

The  percentage  of  single  women  in  cases  of  cancer  of  the  breast  is 
therefore  smaller  than  that  in  the  female  population  generally.! 

(/)  I  pass  by  some  other  conditions  supposed  to  be  favorable  to  the 
occurrence  of  scirrhous  cancers ;  such  as  mental  distress,  particular 
occupations  and  temperaments.  Concerning  all  these,  the  numerical 
evidence  at  present  gained  is  insufiicient  to  justify  any  conclusions. 
But,  respecting  one  point  much  discussed,  namely,  the  general  health  of 
women  at  the  time  when  hard  cancer  is  first  found  in  them,  I  would 
observe  that  a  remarkable  majority  present  the  appearance  of  good 
health.  I  find  that  in  91  cases  in  which  I  have  notes  on  this  point  no 
less  than  66  patients  presented  the  general  characters  of  robust,  or,  at 
least,  good  health  ;  9  were  of  uncertain  or  moderately  good  health ;  and 
only  16  were  sickly  or  feeble.  §  It  does  not  follow  that  all  these  were 
manifestly  ill  when  the  cancer  began  to  form  ;  but,  granting  that  it  may 
have  been  so,  it  would  still  appear  that  scarcely  more  than  one-fourth 
of  the  subjects  of  hard  cancer  are  other  than  apparently  healthy  per- 
sons. From  all  this  it  is  evident,  that,  except  in  relation  to  the  com- 
parative liabilities  of  different  ages,  we  have  little  knowledge  of  the 
events  that  are,  in  any  sense,  the  predisposing  causes  of  hard  cancer. 
Indeed,  so  insignificant  in  their  whole  sum  are  those  that  are  already 

*  Probably  the  proportion  would  be  larger  if  calculated  from  a  larger  number  of  private 
patients.     See  one  of  Mr.  Baker's  tables  in  the  Lecture  on  the  General  Pathology  of  Cancer. 

t  See  p.  348.  Of  79  tumors  not  cancerous  15  were  ascribed  to  injury  or  previous  disease ; 
i.  e.  1  in  nearly  5^-. 

X  See  Insurance  Guide  and  Handbook.     London,  1857. 

§  From  one  of  Mr.  Baker's  tables  (1.  c.)  it  appears  that  only  5.2  per  cent,  of  the  patients 
with  scirrhous  cancer  of  the  breast  were  in  bad  health  at  the  first  observation  of  the  disease. 


546  SCIKEHOUS    CANCEK. 

ascertained,  that,  in  a  large  majority  of  cases,  the  patient  finds  the  can- 
cer by  some  accident.  She  chances  to  touch  her  breast  attentively,  or 
she  feels  some  pain  in  it,  or  her  friends  notice  that  it  is  smaller  or  larger 
than  it  used  to  be ;  and  now,  already,  there  is  a  cancer  of,  it  may  be, 
large  size,  of  whose  origin  no  account  whatever  can  be  rendered. 

The  fact  last  mentioned  may  explain  why  we  so  rarely  have  an  oppor- 
tunity of  seeing  what  a  hard  cancer  is  like  at  its  very  beginning.  I 
have  examined  only  three  that  were  less  than  half  an  inch  in  diameter. 
All  these  were  removed  within  two  months  of  their  being  first  observed, 
and  all  had  the  perfect  cancerous  structure,  such  as  I  have  described  as 
the  type.  I  believe  they  illustrated  what  is  generally  true, — ^namely, 
that  the  cancerous  structure  has,  from  the  first,  its  peculiar  hardness. 
The  formation  of  it  appears  to  be  attended  with  gradually  increasing 
induration,  only  in  the  cases  in  which,  from  the  beginning,  it  afi'ects  the 
whole  glands,  and  those  in  which  it  acquires  even  more  than  usual  hard- 
ness, by  the  gradual  predominance  of  the  increased  and  indurated 
fibrous  tissue. 

From  the  extreme  of  smallness  the  cancer  grows ;  but  at  various 
rates,  in  different  cases,  and  even  in  the  same  case  at  different  times.  I 
believe  no  average  rate  of  increase  can  be  assigned.  Cases  sometimes 
occur,  especially  in  lean,  withered  women,  whose  mammary  glands  share 
in  the  generally  pervading  atrophy,  in  which  two,  three,  or  more  years 
pass  without  any  apparent  increase  in  a  cancer ;  and  the  progress  even 
of  ulcerated  cancer  is,  in  such  patients,  sometimes  scarcely  perceptible, 
even  in  the  lapse  of  years.  On  the  other  hand,  cases  are  found  some- 
times of  most  rapid  increase.  I  saw  such  a  one  last  summer.  A  hard 
cancer  grew  in  five  months  from  the  size  of  the  tip  of  a  finger  to  a  mass 
five  inches  in  diameter.  This  was  in  a  woman  32  years  old,  in  whom 
the  disease  began  while  she  was  suckling,  and  immediately  before,  even 
while  suckling,  she  again  became  pregnant.  Extensive  and  speedy 
sloughing  followed  this  rapid  growth,  and  she  died  in  seven  months  from 
the  first  observation  of  the  disease.* 

We  may  very  probably  connect  this  singularly  rapid  progress  of  a 
hard  cancer  with  the  condition  of  determination  of  blood  to  the  breast 
in  which  it  occurred,  and  to  the  early  age  of  the  patient, — for,  as  a 
general  rule,  though  malignant  tumors  may,  in  their  plan  and  mode  of 
growth,  deviate  never  so  widely  from  the  normal  tissues,  yet  for  their 
rate  of  increase  they  are  dependent,  in  a  certain  measure,  upon  the 
supply  of  blood  and  the  general  activity  of  the  nutritive  processes. 
Hence  it  needs  to  be  always  borne  in  mind,  in  questions  of  operation, 
that  among  the  cancerous  they  who  seem  most  robust  may  succumb 
most  quickly  ;  while  the  aged  and  the  withered  commonly  live  longest 
and  with  least  discomfort. 

*  This  was  the  same  case  as  that  related  by  Mr.  Gay,  in  the  Proc.  of  Pathol.  See  ,  1851-2, 
p.  444. 


MODE     OP     GROWTH.  547 

The  increase  of  a  hard  cancer  appears  to  be  bj  gradual  superaddi- 
tion  of  new  particles  on  the  surface  of  the  mass  already  existing,  and 
in  the  interstices  of  the  tissue  immediately  bounding  it.  It  is  a  nice 
question  to  determine  how  far  from  a  mass  of  cancer  already  formed, 
say,  in  the  breast,  the  parts  to  be  next  added  to  it  will  be  formed. 
Practice  professes  to  have  settled  this  in  the  rule  that  the  whole  mam- 
mary gland  should  be  removed  when  only  a  portion  of  it  is  manifestly 
cancerous.  But  whatever  be  the  facts  on  which  this  rule  is  founded, — 
and  I  believe  they  are  enough  to  justify  it, — they  may  be  explained  by 
the  advantage  resulting  from  the  removal  of  all  the  part  in  which  the 
cancer  would  be  most  apt  to  recur :  they  do  not  prove  that  cancer  is 
already  present  in  the  part  of  the  breast  that  appears  healthy.  It  is, 
indeed,  rare  to  find  more  than  one  cancerous  mass  in  a  mammary  gland. 
I  do  not  remember  to  have  seen  it  more  than  four  times  in  about  100 
cases ;  and  in  one  of  these  the  second  cancer  appeared  to  have  been 
detached,  not  to  have  grown  separately,  from  the  principal  mass.  I 
have  looked  with  microscopic  help  at  the  tissues  close  by  a  hard  cancer, 
and  have  found,  I  think,  cancer-cells  one  or  two  lines  distant  from  the 
apparent  boundary  of  the  chief  mass,  as  if  the  disease  had  already 
begun  where  neither  the  naked  eye  nor  the  finger  could  have  discerned 
it.  Beyond  this  little  distance  I  have  not  found  reason  to  believe  that 
cancerous  matter  in  any  form  exists  in  the  parts  of  a  cancerous  mam- 
mary gland  that  appear  healthy.* 

After  an  uncertain  time  and  extent  of  growth  of  hard  cancer,  Ul- 
ceration almost  constantly  follows.  This  may  ensue  in  various  ways ; 
it  may  be  accelerated  or  retarded  by  many  extraneous  circumstances, 
according  to  which,  also,  its  characters  may  vary ;  but  there  are  two 
modes  of  ulceration  which  are  especially  frequent,  and  are  almost  na- 
tural to  the  course  of  the  cancer. 

In  one  of  these  the  ulceration  begins  superficially,  and  extends  in- 
wards ;  in  the  other  the  changes  leading  to  ulceration  begin  in  the  sub- 
stance of  the  cancer,  and  thence  make  progress  outwards. 

The  superficial  mode  of  ulceration  is  commonly  observed  when  the 
cancerous  growth  has  slowly  reached  and  involved  the  skin.  The  best 
examples  are  those  in  which  the  hard  cancer  first  afiects  a  border  lobe 
of  the  gland.  From  this,  as  it  grows,  it  extends  towards  the  skin,  oc- 
cupying, as  it  extends,  the  subcutaneous  fat  and  all  the  intervening 
tissues  (Fig.  82),  The  skin,  as  the  cancer  approaches,  whether  raised 
or  depressed  towards  it,  adheres  closely  to  its  more  prominent  parts  or 
to  its  whole  surface.    It  becomes  now,  while  cancerous  matter  infiltrates 

*  The  existence  of  cancer-cells  infiltrated  amongst  the  tissues  which  surround  the  actual 
cancerous  tumor,  and  which  to  the  naked  eye  may  appear  to  be  perfectly  healthy,  has, 
however,  now  been  frequently  demonstrated  by  more  than  one  pathologist  (Bennett  on  Can- 
cerous and  Cancroid  Growths,  p.  103;  Van  der  Kolk  "  On  the  Formation  and  Extension 
of  Cancer-cells;"  Br.  &  For.  Med.  Chi.  Rev.,  April,  1855,  p.  390).  For  the  changes  occur- 
ring in  the  tissues  which  lead  to  the  formation  of  the  cancer-cells,  consult  the  note  to  par. 
(3),  Lect.  XXXV,  Part  II. 


548  SCIRRHOUS    CANCER. 

it,  turgid  with  blood,  thin,  tense,  and  glossy,  florid  or  dusky  red,  or 
livid  or  pale  ruddy  brown :  the  congestion  does  not  extend  far,  nor  very 
gradually  fade  out,  as  in  an  inflamed  integument,  but  is  rather  abruptly 
circumscribed,  just  beyond  the  adhesion  of  the  skin  to  the  cancer. 

In  the  next  stage,  the  surface,  in  one  or  more  places,  appears  raw, 
as  if  excoriated ;  or  else,  by  some  sudden  stretching,  it  is  cracked  ;  or 
a  thin  yellow  scab  forms  over  part  of  it,  which,  being  removed,  exposes 
an  excoriated  surface,  and  is  soon  reproduced.  After  a  time  the  exco- 
riated or  the  cracked  surface  appears  as  a  more  certain  ulcer;  scabs  no 
longer  form,  but  a  copious,  acrid,  thin  fluid  exudes.  The  ulcer  is  apt 
to  extend  very  widely;  and  if  there  have  been  more  than  one,  they  soon 
coalesce  ;  but  they  very  rarely  extend  deeply,  and  their  surfaces  rarely 
appear  otherwise  than  pale,  hard,  dry,  and  inactive.  The  growth  of 
the  cancer  continues,  as  usual,  after  the  ulceration  ;  and  with  the  growth 
and  the  involving  of  more  skin,  the  ulceration  is  generally  commensurate. 

Now,  the  ulcer  thus  formed  has,  in  itself,  no  so-called  specific  charac- 
ters :  examined  by  itself,  it  has  not  the  features  assigned  to  the  can- 
cerous ulcer  ;  we  recognize  its  nature  through  that  of  the  mass  beneath 
it.  And  yet  there  is  much  in  the  occurrence  of  this  form  of  ulceration 
that  is  characteristic.  For  we  may  always  notice  that,  though  it  is 
affected  as  if  by  the  destruction  of  the  skin,  and  is  not  unlike  the  ulcera- 
tion that  ensues  over  a  great  firm  tumor  that  has  stretched  the  skin  to 
its  extreme  of  tolerance ;  yet  its  occurrence  is  determined,  not  by  the 
bulk  of  the  cancer  and  the  tension  of  the  skin,  but  by  the  adhesion  and 
confusion  of  the  skin  with  the  cancer.  As  the  cancer  approaches  the 
skin,  so  the  skin,  without  any  stretching,  becomes  thinner  and  thinner; 
then  its  residue  becomes  cancerous;  and  then,  at  length,  it  is  excoriated. 
The  cancer,  exposed  through  the  superficial  ulcer,  is  not  apt  to  be  exu- 
berant: it  does  not  becom.e  or  throw  out  "fungous  growths;"  it  mani- 
fests no  peculiar  tendency  to  further  ulceration.  Granulations*  of  or- 
dinary aspect,  or  such  as  are  only  too  pale  and  hard,  may  cover  it,  and 
it  may  often  scab,  or  even  skin  over ;  or,  if  it  deepen  itself,  it  may  be 
with  no  assumption  of  cancerous  shape,  but  like  a  common  chronic  ulcer 
deepening  by  sloughing  or  acute  inflammation. 

Far  different  from  this,  though  sometimes  superadded  to  it,  is  the 
form  of  ulcer  of  the  breast  which  begins  in  the  substance  of  the  cancer. 
I  will  not  now  enter  upon  the  discussions  about  the  softening  of  cancers 
(as  a  normal  tendency  of  their  structure),  or  upon  those  about  their  in- 
terior suppuration :  I  will  only  state  that,  in  certain  cases  of  hard  can- 
cer, we  find  cavities  filled  and  walled  in  with  softened  and  disintegrated 
cancerous  matter.  In  these  the  dull,  ochre-yellow,  soft  material,  con- 
sists mainly  of  degenerate  cancer-cells  and  their  debris.  It  may  be 
mingled  with  an  ill-formed  pus  ;  and  as  these  mingled  materials  increase 
and  enlarge  the  cavity,  so,  finally,  they  are  discharged  by  ulceration. 

*  These  granulations  are  formed  of  cancer-structures ;  yet,  let  it  be  observed,  they  take 
the  shape  and  construction  of  such  as  are  formed  in  the  healing  of  any  common  ulcer. 


ULCERATION.  549 

Their  discharge  leaves  in  the  solid  mass  of  cancer  a  deep  excavated 
ulcer,  a  cavity  like  that  of  a  widely  open  abscess,  except  in  that  it  is 
all  walled  in  with  cancerous  matter,  the  remains  of  the  solid  mass. 
Then,  as  the  walls  of  this  cavity  ulcerate  on  their  internal  surface,  and 
at  the  margin  of  the  opening  into  it,  so  their  outer  surface  is  increased 
by  superaddition  of  the  cancerous  matter ;  i.  e.  as  one  part  of  the  can- 
cer wastes,  by  ejection  of  its  ulcerating  surface,  so  is  another  part  in- 
creased. Hence  the  ulcer  constantly  enlarges :  but  the  ulceration  does 
not  destroy  the  cancer  ;  that  increases  the  faster  of  the  two,  extending 
more  and  more,  both  widely  and  deeply,  and  involving  different  tissues 
more  and  more  continually,  to  the  end  of  life.  In  all  its  course  it 
yields  a  thin,  ichorous,  and  often  irritating  discharge,  that  smells 
strongly,  and  almost  peculiarly. 

In  all  its  later  course,  when  not  disturbed,  this  form  of  cancerous 
ulcer  has  certain  characteristic  features,  which  are  chiefly  due  to  the 
concurrent  processes  of  ulceration  at  one  surface,  and  of  predominating 
fresh  formation  at  the  other  surface,  of  the  cancer.  Thus  the  edge  of 
the  ulcer  is  raised  by  the  exuberant  formation  of  cancer  in  and  beneath 
the  boundary  of  skin  :  exuberance  of  the  growth  necessarily  everts  the 
margin,  which  is  too  rigid  to  stretch ;  and  the  margin  thus  raised  and 
everted  is  hard,  nodular,  and  sinuous,  because  the  growth  under  it,  like 
the  primary  cancer,  is  formed  after  a  knotted  tuberous  plan.  The  base 
of  the  ulcerated  cavity  is  similarly  hard  and  knotted,  or  covered  with 
hard,  coarse,  cancerous  granulations.  Lastly,  when  we  cut  through 
such  an  ulcer,  we  divide  a  thick  layer  of  cancer,  infiltrated  in  the  sub- 
jacent tissues,  before  the  knife  reaches  any  normal  structures. 

It  would  be  vain  to  try  to  describe  all  the  various  and  dreadful  forms 
of  ulcer  that  follow  the  acute  inflammations  and  sloughings  of  scirrhous 
cancers,  or  all  the  aggravations  of  the  disease  by  hemorrhage  from  the 
ulcerating  surface,  or  by  obstructions  of  the  lymphatics  or  the  veins. 
As  I  pass  by  the  efi'ects  of  these  accidents  of  the  disease,  in  describing 
its  structures,  so,  much  more,  must  I  now.  Only,  I  would  state  that 
these  are  the  events  which  produce,  in  cancerous  patients,  the  most 
rapid  and  the  most  painful  deaths.  When  inflammation  is  averted  from 
it,  a  cancerous  ulcer  may  exist  very  long,  and  make  slow  progress, 
without  extreme  pain  or  disturbance  of  the  health ;  it  may  be  no  worse 
a  disease  than  the  "occult"  cancerous  growth;  and  ten  or  more  years 
may  pass  with  the  health  scarcely  more  impaired  than  at  the  beginning. 
Sir  B.  Brodie*  has  related  two  such  cases ;  and  I  may  add  to  them 
one  which  I  have  lately  seen  in  a  cook,  who  has  for  eight  years  had 
hard  cancer  of  the  breast.  During  five  of  these  years  it  has  been 
ulcerating,  and  yet  none  of  those  with  whom  she  lives  is  aware  that  she 
is  diseased. 

Such  cases  of  arrest  of  cancer  are,  however,  very  rare  ;   they  are 

*  Lectures  on  Surgery  and  Pathology,  p.  21L 


550  SCIRRHOUS    CANCER 

only  rare  exceptions  to  the  general  rule  of  that  progress  towards  death, 
the  rate  of  Avhich  is  far  less  often  retarded  than  it  is  accelerated  by 
such  accidental  inflammations  of  the  cancer  as  I  have  already  referred 
to.  Still  more  rare  are  the  exceptions  in  which  an  ulcerated  cancer 
heals.  Such  cases,  however,  may  be  met  with,  especially  among  the 
examples  of  the  more  superficial  ulcer.  The  ulcers  may  be  skinned  over 
(as  any  common  ulcer  usually  is),  and  the  cancerous  mass  beneath  it 
may  waste  and  be  condensed,  so  that  the  disease  may  be  regarded  as 
obsolete,  if  not  cured. 

The  conditions  under  which  this  healing  and  regress  of  the  ulcerated 
cancer  may  take  place  are,  I  believe,  as  yet  quite  unknown.  In  the 
following  case  they  seem  to  be  connected  with  the  development  of 
tuberculous  disease,  as  if- the  patient's  diathesis  had  changed,  and  the 
cancer  had  wasted  through  want  of  appropriate  materials  in  the  blood. 

I  removed  the  breast  of  a  woman  25  years  old,  including  a  large 
mass  of  well-marked  scirrhous  cancer  of  three  months'  duration.  She 
appeared  in  good  general  health,  and  could  assign  no  cause  for  the 
disease.  The  progress  of  the  cancer  had  been  very  rapid ;  it  had  lately 
affected  the  skin  near  the  nipple  ;  and  all  its  characters  were  those  of 
the  acute  form.  The  axillary  glands  had  been  enlarged  and  hard,  but 
had  subsided  with  rest  and  soothing  treatment.  Six  months  after  the 
operation,  and  after  the  patient  had  been  for  four  months  apparently 
well,  cancerous  disease  reappeared  in  the  skin  about  the  scar,  and  in 
the  axillary  glands.  In  the  skin  it  rapidly  increased ;  numerous  tu- 
bercles formed,  coalesced,  and  ulcerated  ;  and  the  ulceration  extended 
till  it  occupied  nearly  the  whole  region  of  the  scar,  and  often  bled  pro- 
fusely. Thus  the  disease  appeared  progressive  for  twelve  months  after 
its  reappearance  ;  but  at  the  end  of  this  time  the  ulcer  began  to  heal, 
and  in  the  next  six  months  a  nearly  complete  cicatrix  was  formed ; 
only  a  very  small  unhealed  surface  remained,  like  an  excoriation 
covered  with  a  scab.  The  disease  in  the  axilla,  also,  nearly  subsided  ; 
one  hard  lump  alone  remained  of  what  had  been  a  large  cluster  of  hard 
glands.  But  even  during  and  after  the  healing  of  the  cancerous  ulcer 
she  lost  strength,  and  became  much  thinner,  and  at  length,  gradually 
sinking,  she  died  nearly  two  years  after  the  operation,  and  six  months 
after  the  cancer  had  so  nearly  healed. 

In  the  examination  after  death  I  found,  in  the  situation  of  the  scar 
of  the  operation,  a  low  nodular  mass  of  the  very  hardest  and  densest 
cancer,  extending  through  the  substance  of  the  scar  and  the  pectoral 
muscle,  and  nearly  all  covered  by  thin  scar-like  tissue.  In  the  axilla 
was  one  hard  cancerous  gland,  and  in  the  liver  were  many  masses  of 
cancer  as  dense  and  hard  as  that  on  the  chest.  In  all  these  parts  the 
cancer  structures  appeared  to  be  condensed  and  contracted  to  their  ex- 
treme limit. 

The  lungs  contained  no  cancer,  but  were  full  of  groups  of  gray  suc- 
culent tubercles  and  grayish  tuberculous  infiltration  in  every  part  ex- 


PAIN.  551 

cept  their  apices,  where  were  numerous  small  irregular  tuberculous 
cavities.     The  other  organs  appeared  healthy. 

The  contrast  was  very  striking,  in  this  case,  between  the  appearances 
of  active  recent  progress  in  the  tuberculous  disease,  and  of  the  opposite 
course  in  the  cancerous  disease  found  after  death  ;  and  I  can  hardly 
doubt  that,  during  life,  the  progress  of  the  one  had  been  at  first  coinci- 
dent, and  then  commensurate,  with  the  regress  of  the  other. 

But  leaving,  for  the  present,  the  questions  of  the  relations  between 
cancerous  and  tuberculous  disease,  I  would  observe  that  this  case  illus- 
trated the  two  modes  of  healing  that  may  occur  in  cancer  ;  namely,  the 
formation  of  a  scar  over  the  ulcer,  and  the  shrivelling  of  the  cancerous 
mass.  The  first  appears  to  be  accomplished  according  to  the  ordinary 
method  of  the  healing  of  ulcers  :  the  second  is  probably  similar  to  the 
contraction  and  induration  of  deposits  of  inflammatory  lymph.  So  far 
as  I  know,  the  process  of  superficial  healing  has  not  been  minutely  ex- 
amined in  relation  to  the  changes  ensuing  in  the  elementary  structures 
of  the  cancer.  Only,  one  sees  cuticle  forming  on  the  surface  of  appa- 
rently cancerous  granulations.  In  the  process  of  shrivelling  the  can- 
cerous mass  becomes  smaller,  denser,  drier,  and  harder ;  it  contracts  and 
draws  in  more  tightly  the  adjacent  parts;  it  yields  no  turbid  "juice," 
but  a  thin  serous-looking  fluid  may  be  scraped  from  it  in  very  small 
quantity.  One  finds  in  such  fluid,  sparingly  distributed,  cancer-cells 
and  nuclei,  with  molecular  and  granular  debris-like  matter;  but  (in  the 
breast)  the  chief  mass  of  the  shrivelled  cancer  seems  to  consist  of  the 
proper  tissues  of  the  organs  indurated  and  condensed.  We  cannot 
doubt  that,  during  such  a  change,  cancer-cells  and  other  elemental 
structures  are  absorbed ;  but  the  changes  preparatory  thereto  are  not, 
I  think,  satisfactorily  explained.* 

Such  may  serve  as  a  general  history  of  the  progress  of  a  scirrhous 
cancer  in  the  breast.  Let  me  add  a  brief  notice  of  the  pain,  cachexia, 
and  some  other  of  its  accompaniments. 

Among  the  many  inconstancies  in  the  life  of  cancers,  none,  I  think, 
is  more  striking  than  that  which  relates  to  the  attendant  pain.  One 
sees  cases  sometimes,  that  run  through  their  whole  career  without  any 
pain.  In  a  case  of  deeply  ulcerated  cancer  of  the  breast,  the  patient, 
who  had  also  a  cluster  of  cancerous  axillary  glands,  begged  that  the 
disease  might  be  removed,  but  only  because  it  was  "such  a  terrible 
sight."  It  had  never  once  given  her  the  least  pain.  In  another  case, 
a  patient,  from  whom  a  cancer  involving  the  whole  mammary  gland  was 
removed,  was  quite  unaware  of  any  pain  or  other  affection  in  her  breast 
till,  a  few  weeks  before  the  operation,  some  of  her  friends  observed  its 
diminished  size.  The  largest  hard  cancer  of  the  breast  that  I  have  yet 
removed  was  equally  painless.     Another  patient,  who  died  with  rapidly 

*  The  whole  process  is  minutely  discussed  by  Virchow,  in  his  Ar  jhiv,  B.  i,  p.  185,  etseq. 


652  SCIRRHOUS    CANCER. 

progressive  and  ulcerated  cancer,  had  not  a  pain  in  its  two  years' 
duration. 

On  the  other  hand,  we  sometimes  meet  with  cases  that  quite  exem- 
plify the  agony  which  is  commonly  regarded  as  the  constant  accompa- 
niment of  hard  cancer.  In  such  a  case  the  patient  could  "  wish  herself 
dead,"  for  the  sake  of  freedom  from  the  fierce  anguish  of  her  pain, — 
pain  as  if  a  hot  dart  were  thrust  swiftly  through  her  breast,  or  right 
through  her  chest, — pain,  starting  with  a  sudden  pang,  and  then  seem- 
ing to  vibrate  till  it  fades  out  slowly ;  or  sometimes  more  abiding  pain, 
likened  to  the  burning  and  scalding  of  hot  water  or  of  molten  lead. 
With  such  resemblances  as  these  do  patients  strive  to  describe  the 
agonies,  which  are  indeed  beyond  description,  and  of  which  the  peculiar 
intensity  is  perhaps  best  evidenced  by  the  fact,  that  the  sufferers  almost 
always  thus  liken  them  to  some  imaginary  pain,  and  not  to  anything 
that  they  have  felt  before.  The  memories  of  those  who  have  suffered 
even  the  pains  of  child-birth  supply  no  parallel  of  that  which  is  now 
endured ;  the  imagination  alone  can  suggest  the  things  with  which  it 
may  be  compared. 

Now,  although  both  these  classes  of  cases  be  exceptions  from  the 
general  rule  concerning  the  painfulness  of  cancer  of  the  breast,  yet  they 
are  interesting,  both  for  their  own  sakes,  and  because  they  illustrate 
the  nature  of  the  pain  attending  tumors  ;  they  show  that  it  is,  in  great 
measure,  independent  of  the  merely  mechanical  condition  of  the  parts  ; 
that  it  is  due  not  to  pressure  on  the  nerves,  or  to  their  tension  or  dis- 
placement, but  rather  must  be  considered  as  a  subjective  sensation,  a 
neuralgia,  due  to  some  unknoAvn  morbid  state  of  nerve-force.  That 
this  is  so  is  nearly  sure  from  the  fact,  that  if  we  compare  the  most 
painful  and  the  least  painful  cancers  with  each  other,  we  may  find  their 
structure  and  relations  exactly  similar.  Any  of  the  forms  that  I  have 
described  may  in  one  case  be  attended  with  intense  pain,  in  another 
may  exist  without  discomfort.  They  may  present  no  other  diff"erence 
than  the  immense  difference  of  painfulness. 

However,  as  I  have  said,  both  the  very  painful  cancers  and  those 
that  are  always  without  pain  are  exceptional  cases.  The  more  general 
rule  seems  to  be :  (1)  that  in  the  early  part  of  its  course  (for  instance, 
in  ordinary  cases  for  the  first  year  or  year  and  a  half),  the  hard  cancer 
of  the  breast  is  either  not  painful  at  all,  or  gives  only  slight  and  occa- 
sional pain,  or  is  only  made  painful  by  handling  it ;  (2)  that  during 
this  time  its  pain  has  usually  no  peculiar  character ;  is  not  generally 
lancinating,  but  more  often,  and  especially  after  manipulation,  is  dull 
and  heavy ;  (3)  that  after  this  time  the  cancer  becomes  progressively 
more  painful,  and  the  pain  acquires  more  of  the  darting  and  lancinating 
character ;  (4)  that  the  pain  is  generally  increased  when  the  cancer 
grows  quickly,  and  more  constantly  when  it  is  inflamed  or  ulcerating, 
or  about  to  slough ;  (5)  that  the  pain  is  yet  more  intense  when  the 


MULTIPLICATION.  553 

cancer  is  progressively  ulcerating,  and  now  adds  to  its  lancinating  cha- 
racter, or  substitutes  for  it,  the  hot  burning  or  scalding  sensation. 

With  the  advance  of  the  local  disease  the  signs  of  general  disorder 
of  the  health  usually  increase;  and  the  cancerous  "cachexia,"  Avhich 
may  at  first  have  been  absent  or  obscure,  is  established.  It  would  be 
very  difficult  to  describe  this  state  exactly,  and  much  more  so  to  analyze 
it.  The  best  description  of  its  most  frequent  characters  is,  I  think,  that 
by  Sir  Charles  Bell  :*  "  The  general  condition  of  the  patient  is  pitiable. 
Suffering  much  bodily,  and  everything  most  frightful  present  to  the 
imagination,  a  continual  hectic  preys  upon  her,  which  is  shown  in  in- 
creasing emaciation.  The  countenance  is  pale  and  anxious,  with  a  slight 
leaden  hue ;  the  features  have  become  pinched,  the  lips  and  nostrils 
slightly  livid  ;  the  pulse  is  frequent ;  the  pains  are  severe.  In  the  hard 
tumors  the  pain  is  stinging  or  sharp  ;  on  the  exposed  surface  it  is  burn- 
ing and  sore.  Pains,  like  those  of  rheumatism,  extend  over  the  body, 
especially  to  the  back  and  lower  part  of  the  spine  ;  the  hips  and  shoulders 
are  subject  to  those  pains.  Successively  the  glands  of  the  axilla  and 
those  above  the  clavicle  become  diseased.  Severe  pains  shoot  down  the 
arm  of  the  affected  side.  It  swells  to  an  alarming  degree  and  lies  im- 
movable. 

"  At  length  there  is  nausea  and  weakness  of  digestion :  a  tickling 
cough  distresses  her ;  severe  stitches  strike  through  the  side  ;  the  pulse 
becomes  rapid  and  faltering ;  the  surface  cadaverous  ;  the  breathing 
anxious;  and  so  she  sinks." 

This  vivid  sketch  is  generally  true  of,  perhaps,  a  majority  of  the 
cases  of  hard  cancer  of  the  breast ;  but  I  doubt  whether  any  one  of  the 
signs  of  cachexia  here  indicated  is  constantly  present.  Even  emacia- 
tion is  not  so ;  for  many  die,  exhausted  by  the  suffering  and  discharge, 
in  whom  fat  is  still  abundant,  or  appears  even  increased  about  the 
cancer  itself.  This  want  of  constancy  adds  greatly  to  the  difficulty  of 
analyzing  the  phenomena  of  the  cachexia.  We  can  see  little  more  than 
that  they  include  two  mingled  groups  of  symptoms :  of  which  one  may 
be  called  "  primary,"  depending  on  the  increasing  morbid  and  peculiar 
cancerous  condition  of  the  blood,  and  the  other  "secondary,"  depend- 
ing on  the  local  disease  and  the  effects  produced  on  the  blood  by  its 
pain,  discharge,  hemorrhage,  and  various  accidents.  In  the  confusion 
of  symptoms  thus  arising,  analysis  seems  impossible. 

The  last  concomitant  of  the  scirrhous  cancers  of  the  breast,  that  I 
need  now  speak  of,  is  their  multiplication ;  but  I  will  here  only  enume- 
rate the  methods  in  which  this  may  happen  ;  for  its  explanation  belongs 
to  the  general  pathology.     These,  then,  are  the  methods : 

First,  and  most  frequently,  the  disease  extends  to  the  lymphatic  ves- 

*  Medico-Chirurgical  Transactions,  xii,  223. 
36 


554  SCIRRHOUS    CANCER    OF    THE    BREAST. 

sels  and  glands ;  or  to  their  contents ;  for  it  seems  most  probable  that, 
as  Mr.  Simon  has  suggested,  its  progress  is  along  the  continuity  of  the 
lymph  from  the  breast  to  the  glands. 

(2)  Next,  I  think,  in  order  of  frequency,  are  the  multiplications  of  the 
cancer  in  the  same  region  ;  not,  indeed,  in  the  same  gland,  but  in  the 
skin  and  muscles  near  it,  and  then  in  areas  gradually  widening  round  it. 

(3)  It  is  less  frequent  for  the  scirrhous  cancer  to  appear  secondarily 
in  the  similar  tissue  of  the  opposite  breast.  Indeed,  its  multiplication, 
if  it  may  be  so  considered,  is  less  frequent  in  this  direction  than  in  that 
of  some  organs  of  more  different  texture,  especially  the  bones,  the  liver, 
and  the  lungs.  These,  among  parts  distant  from  its  primary  seat,  are 
by  far  the  most  frequent  seats  of  secondary  disease  ;  but  with  these,  or, 
much  more  rarely,  alone,  nearly  every  tissue  has  been  found  affected.* 

The  structures  of  many  examples  of  these  secondary  cancers  are 
already  described  (p.  533,  &c,)  It  is  often  said  that  the  cancers  which 
appear  as  secondary  to  the  scirrhus  of  the  breast  are  of  the  medullary 
kind ;  an  error  which  I  think  must  have  arisen  from  the  belief  that  the 
scirrhous  cancer  is  always  fibrous.  I  have  already  explained  that  it 
very  rarely  is  so,  and  only  appears  to  be  so  when  it  grows  in  parts  con- 
taining fibrous  tissue ;  and  that  what  has  been  generally  deemed  the 
fibrous  structure  of  the  cancer  is  usually  that  of  the  organ  in  which  it 
is  seated.  The  secondary  cancers  are,  usually,  in  all  points  conformed 
to  the  primary,  and  consist,  like  them,  essentially  of  cells  compacted 
into  a  hard  mass.  They  may  appear  fibrous  when  growing  in  fibrous 
organs :  but  inasmuch  as  their  more  usual  seats  are  in  organs  that 
naturally  contain  little  or  no  fibrous  tissue,  they  are  more  commonly 
formed  of  cell-structures  alone.  The  change  from  hard  to  soft  cancer 
is  rare ;  it  may,  however,  take  place,  especially  in  the  latest  growths ; 
and  it  is  the  best  illustration  of  the  afiinity  between  the  two  forms  of 
the  disease. 

To  end  this  history  of  the  scirrhous  cancers  of  the  breast,  I  must 
speak  of  their  duration.  There  is  a  striking  contrast  between  the  cer- 
tain issue,  and  the  uncertain  rate,  of  their  progress.  Cases  are  on 
record  in  which  life  has  been  ended  in  four  months,  and  others  in  which 
it  has  been  prolonged  to  twenty-five  years;  but  I  am  not  aware  of  a 
single  clear  instance  of  recovery  ;  of  such  recovery,  that  is,  as  that  the 
patient  should  live  for  more  than  ten  years  free  from  the  disease,  or 
with  the  disease  stationary.  The  nearest  approach  to  this  that  I  have 
yet  seen  was  in  the  case  of  a  woman,  from  whom,  at  51  years  of  age,  I 
removed  a  cancerous  breast  of  two  years'  duration,  and  numerous  axil- 
lary glands.  She  lived  and  worked  hard  for  llj  years  without  any 
apparent  return  of  the  disease,  and  died  with  progressive  muscular 
atrophy  of  the  tongue  and  pharynx.     After  death,  no  trace  of  cancer 

*  M.  Lebert  has  given  a  table  of  the  relative  frequencies  of  secondary  cancers  in  differ- 
ent organs  after  primary  disease  in  the  breast.  It  is  dravi^n  from  23  autopsies.  Mr.  Birkett 
has  given  a  similar  table  of  37  cases  examined  after  death. 


12 

u 

18   " 

18 

a 

24   « 

24 

(( 

30   " 

30 

" 

36   " 

3 

(1 

4  years. 

4 

a 

6   " 

6 

« 

8   " 

8 

" 

10   " 

10 

" 

20   " 

MULTIPLICATION.  555 

was  to  be  found,  except  a  few  very  hard  white  masses  in  the  liver  and 
gastro-hepatic  omentum. 

The  average  duration  of  life,  from  the  patient's  first  observation  of 
the  disease,  is  a  little  more  than  four  years.  In  66  cases,  tabulated 
without  selection,  I  find  it  something  more  than  49  months.* 

Among  61  of  these,  7  died  in  between  6  and  12  months. 

7  « 

8  " 
10  " 

2  " 
12   '  " 

6  " 

3  " 
1  " 
'5 

The  cases  are  too  few  to  allow  of  many  conclusions ;  but  they  suffice 
at  least  to  show  that  the  average  duration  of  life  in  these  cancerous  pa- 
tients would  afford  a  wrong  estimate  of  the  probable  duration  of  life  in 
any  single  case  :  since  the  number  who  live  beyond  the  average  is  far 
less  than  that  of  those  who  die  within  it,  and  the  mean  average  is  raised 
by  the  lives  of  those  few  who  survive  long  periods. 

It  seems  at  present  impossible  to  estimate  many  of  the  conditions 
which  determine  the  duration  of  life ;  but  none  among  them  seems  more 
weighty  than  the  age  at  which  the  disease  commences.  There  are, 
indeed,  many  exceptions  to  the  rule,  yet,  on  the  whole,  the  earlier  the 
disease  begins  the  more  rapid  is  its  course.  Thus,  among  those  who 
lived  not  more  than  18  months,  I  find  that  the  average  age  at  which  the 
disease  was  first  observed  was  43  years.  Among  those  who  lived  be- 
tween 18  and  36  months,  it  was  51  years  ;  and  among  those  who  lived 
between  3  and  8  years,  the  average  at  the  commencement  of  the  disease 
was  56.7  years. t 

In  all  the  cases  from  which  the  foregoing  deductions  were  made,  the 
disease  ran  its  course  uninterrupted  by  operative  treatment. 

In  47  cases,  in  which  the  cancer  was  once  or  more  removed  by  opera- 
tion, the  average  duration  of  life,  after  the  first  observation  of  the  dis- 
ease,  was  again  something  more  than  49  months.     I  believe,  therefore, 

*  I  say  "  something  more,"  because  I  have  reckoned  in  the  cases  of  five  patients  who  are 
still  living,  more  than  49  months  from  the  first  observation  of  the  disease.  In  the  table  on 
the  next  page  six  similar  cases  are  reckoned  with  those  from  which  the  general  average  is 
derived.  Of  the  patients  already  dead,  the  average  duration  was,  for  those  in  this  table, 
49.36  months;  for  those  in  the  next  table,  48.9  months.  The  difference  is  far  less  than  I 
believed  it  to  be  when  the  lecture  was  delivered  :  I  was  deceived  at  that  time  by  using  too 
small  a  number  of  cases,  and  a  table  containing  some  cases  that  were  recorded  only  because 
they  were  examples  of  rarely  long  life. 

f  The  average  for  those  who  lived  more  than  8  years  was  only  45  years.  But  this  will 
not  materially  invalidate  the  rule  as  stated  above,  if,  as  I  suspect,  these  long  lives  owe  their 
unusual  duration  to  something  interfering  with  the  more  normal  progress  of  the  disease;  and 
if,  as  is  also  probable,  the  deaths  from  cancers  commencing  in  those  whose  average  age  is 
near  60  are  often  prevented  or  accelerated  by  the  other  diseases  which  destroy  so  large  a 
proportion  of  persons  living  to  that  age. 


556  SCIRRHOUS    CANCER    OF    THE    BREAST. 

that  the  removal  of  the  local  disease  makes  no  material  difference  in  the 
average  duration  of  life ;  but  if  the  following  table  be  compared  with 
that  on  the  preceding  page,  it  will  seem  probable  that  the  course  of  the 
more  rapid  cases  is  retarded  by  the  operation.  Among  41  of  those 
patients  who  are  already  dead, — 

4  died  in  between    6  and  12  months. 


4 

a 

12 

11 

18 

Cl 

2 

u 

18 

u 

24 

11 

5 

t( 

24 

» 

30 

11 

3 

» 

30 

u 

36 

11 

11 

u 

3 

(( 

4 

years. 

8 

(t 

4 

(1 

6 

" 

2 

(( 

6 

" 

8 

" 

1 

IC 

8 

" 

10 

u 

1 

(( 

10 

(1 

20 

11 

It  would  seem,  I  repeat,  as  if  the  course  of  cancerous  disease,  that 
otherwise  would  be  very  rapid,  were  retarded  by  the  removal  of  the 
growth  ;  for,  while  in  some  respects  the  two  tables  closely  correspond, 
it  may  yet  be  noticed  that  the  proportion  of  those  who  die  within  two 
years  is  36  per  cent,  of  those  in  whom  the  disease  is  allowed  to  run  its 
course,  and  only  24  per  cent,  of  those  from  whom  the  growth  is  once  or 
more  removed.  The  number  of  cases  from  which  this  is  concluded  is 
indeed  small ;  but  other  facts  might  lead  us  to  expect  the  same,  espe- 
cially that  in  general  the  most  rapidly  fatal  cases  are  those  in  which  the 
local  disease  has  the  greatest  share  in  the  death.* 

The  constitutional  part  of  the  cancerous  disease,  little,  if  at  all, 
affected  by  the  removal  of  the  local  part,  manifests  itself  by  the  recur- 
rence of  cancerous  growths  in  or  near  the  seat  of  operation,  or  in  the 
lymphatics  of  the  breast,  or  in  some  more  distant  part.  In  74  cases, 
comprising  21  collected  by  M.  Lebert,  and  53  by  myself,  the  periods  of 
recurrence  after  the  operation  were  as  follows : 

Between 


1  and 

3 

months  in 

23 

3    " 

6 

" 

22 

6    " 

9 

<t 

8 

9    " 

12 

11 

6 

12    " 

24 

i: 

7 

2    " 

3 

years  in 

3 

3    " 

4 

" 

1 

4    " 

6 

" 

2 

6    " 

8 

11 

2 

*  Tables  published  by  Mr.  Baker  (1.  c.)  seem  to  prove  that,  by  a  better  selection  of  cases 
for  operation  than  had  been  made  in  the  instances  from  which  the  above  tables  were  con- 
structed, much  better  results  may  be  obtained.  Thus  in  84  cases,  of  which  by  far  the  greater 
number  occurred  after  the  publication  of  the  first  edition  of  these  lectures,  and  on  which  no 
operation  was  performed,  the  average  duration  of  life  was  43  months  ;  and  in  62  cases  on 
which  operations  were  performed,  the  average  was  55.6  months.  Mr.  Sibley's  tables  in- 
dicate a  still  greater  difference:  the  average  in  cases  of  removal  of  the  breast  being  56.6 
months,  and  of  non-removal  32.25  months.  (Med.-Chir.  Trans.,  vol.  xlii.)  To  the  same 
better  selection  of  cases  it  may  probably  be  referred  that,  according  to  one  of  Mr.  Baker's 
tables,  only  42  per  cent,  of  the  recurrences  occurred  within  six  months  of  the  operation,  in- 
stead of  the  60  per  cent,  shown  in  the  text. 


EFFECTS    OF    REMOVAL.  657 

Neither  of  us  lias  jet  met  with  a  case  in  which  recurrence  was  de- 
layed beyond  eight  years.* 

The  table  confirms  the  view  that  the  removal  of  the  local  has  little 
influence  on  the  constitutional  element  of  the  disease ;  for  even  if  we 
believe  that  many  of  the  cases,  reported  as  recurrences  between  1  and 
3  months,  were  examples  of  continuous,  rather  than  of  recurrent,  local 
disease,  still  the  small  proportion  of  cases  in  which  recurrence  was  de- 
layed more  than  twelve  months  after  the  operation  might  suggest  the 
belief,  that  after  an  operation  the  constitutional  disease  continues  and 
increases,  till  it  manifests  itself  in  recurrent  local  disease,  in  about  the 
same  time  as  it  might  have  appeared  in  some  secondary  cancer,  if  the 
operation  had  not  been  performed. 

The  recurrent  local  disease  appears  generally  to  be  less  intense  than 
the  primary.  This  is  probable,  both  from  the  fact  mentioned  at  page 
556,  respecting  the  smaller  proportion  of  rapidly  fatal  cases  in  those 
submitted  to  operation,  and  from  the  fact  that  when  recurrent  cancers 
are  removed,  the  second  recurrences  sometimes  ensue  more  slowly  than 
the  first  did.  In  12  cases  in  which  recurrent  cancers  of  the  breast 
were  removed,  I  find  that  the  period  of  second  recurrence,  i.  e.  the 
interval  between  the  second  operation  and  the  reappearance  of  the 
disease,  was 

Between  1  and  3  months  in  4  cases. 

"         3     "     6         "  3       " 

«         6     "  12         "  1       " 

"         2     "    3  years  in      2       " 
«         5     "    7         "  2      " 

And,  among  these  late-recurring  cases,  is  one  in  which  the  first  re- 
currence was  after  24  months,  the  second  after  60 ;  another  of  first 
recurrence  in  12  months,  and  second  in  84 ;  and  another  of  first  recur- 
rence in  2  months,  and  second  in  24. 

It  is  believed  by  some  that  the  cancer  of  the  breast  (and  they  would 
say  the  same  of  other  cancers)  is  in  the  first  instance  a  local  disease ; 
and  that  the  constitutional  disease  which  is  manifested  by  recurrence 
after  operation,  or  by  multiplicity  of  cancers,  or  by  cachexia,  is  the 
consequence  of  the  slowly  acting  influence  of  the  local  disease. 

If  this  opinion  were  true,  we  ought  to  find  that  the  average  interval 
between  removal  of  the  disease  and  its  recurrence  bears  an  inverse  pro- 
portion to  the  time  of  duration  of  the  cancer  before  removal.  No  such 
proportion,  however,  exists  :  nor  does  it  even  appear  that  recurrence 
is,  on  the  whole,  later  after  early,  than  after  delayed,  operations.  The 
following  table  shows  the  times  of  recurrence  in  56  cases,  in  which  the 

*  Since  the  first  edition,  a  patient  has  lived  9|-  years  after  operation  without  any  sign  of 
recurrence,  and  perhaps  the  case  mentioned  at  p.  554  may  be  considered  as  another  instance 
of  recurrence  delayed  beyond  eight  years. 


558 


SCIEEHOUS  CANCER  OF  THE  BREAST. 


removal  of  tlie   cancer  was  effected  within  various  periods,  from  three 
months  to  four  years,  after  its  first  appearance : 


Time  of  Operation. 

Within 

6  months. 

Under  3  months,         .         .     4 

Between  3  and  6  months,    .     5 

"       6    "  12       "  .     5 

"     12    "  24       "  .     9 

"     24    "  48        "  .7 


Time  of 

R 

Bcurrences. 

Between 

More  than 

No.  of 

6  &  12  months. 

12  months. 

Cases. 

2 

2 

8 

2 

2 

9 

4 

5 

14 

1 

3 

13 

3 

2 

12 

The  following  table  shows  that  the  duration  of  life  is  not  greater 
after  early  than  after  late  operations :  but  this  is,  doubtless,  because 
the  most  acute  cancers  are,  on  the  whole,  the  most  early  removed : 


Time  of  Operation. 
ler  3  months, 

Average  duration 
of  life  after  the 
operation. 
.20  months. 

Numher 

of 

Cases. 

4 

ween  3  and  6  months,    . 

.      12 

C( 

6 

"         6    "   12        " 

.      39 

u 

8 

«       12    "  24        "           .          . 

.      17 

" 

8 

"       24    "  48        "           .          . 

.      21 

cc 

5 

Lastly,  I  can  find,  in  the  cases  I  have  collected,  no  confirmation  of 
the  received  (and  possibly  true)  opinion,  that  when  some  of  the  axillary 
lymphatic  glands  are  cancerous,  and  are  removed  with  the  cancerous 
breast,  the  recurrence  of  the  disease,  and  its  fatal  termination,  are  more 
speedy  than  after  operations  in  which  the  breast  alone  is  removed,  the 
glands  appearing  healthy.  In  20  cases  of  removal  of  the  breast  alone, 
the  average  time  of  recurrence  was  eight  months,  and  that  of  death 
twenty-four  months,  after  the  operation :  while  in  10  cases  of  the  re- 
moval of  the  breast  with  some  axillary  glands,  the  recurrence  ensued, 
on  an  average,  in  thirteen  months,  and  the  death  in  twenty-four  months, 
after  the  operation. 

I  find  as  little  clearly  recorded  evidence  for  the  similarly  unfavorable 
opinion  generally  entertained  of  the  effects  of  the  removal  of  cancers 
adherent  to  the  skin,  or  already  ulcerated.  I  would  be  far  from  hold- 
ing that  these  opinions  are  incorrect ;  but  their  truth  is  not  yet  proved  ; 
and  it  is  not  supported  by  such  cases  as  I  have  been  able  to  collect. 
The  recurrences  and  deaths  after  these  "  unfavorable"  cases  are  indeed 
sure  and  speedy ;  but  I  am  not  yet  clear  that  they  are  more  so  than 
those  are  which  follow  the  operations  that  are  undertaken  in  some  of 
what  are  deemed  the  most  favorable  cases. 


The  foregoing  facts,  relating  to  the  influence  of  the  removal  of  can- 
cerous breasts  on  the  progress  of  the  disease,  and  on  the  duration  of 
life,  may  be  considered  from  two  points  of  view, — the  pathological  and 
the  practical.     Mere  pathology  may  study  these  operations  as  so  many 


EFFECTS     OF    REMOVAL.  559 

experiments  for  determining  the  mutual  influences  of  the  local  and  the 
constitutional  elements  of  the  cancerous  disease ;  or,  the  questions 
entertained  bj  some  respecting  their  priority ;  or,  the  share  taken  by 
each  in  destroying  life.  I  trust  that  the  tables  I  have  given  may  be  of 
some  avail  for  the  settlement  of  these  and  other  similar  questions  to 
which  I  shall  again  refer  in  the  concluding  lectures.  But  at  present, 
few  of  the  facts,  which  mere  pathology  can  gather  from  inquiries  such 
as  these,  are  sufficiently  clear  or  pronounced  to  serve  for  guidance  in 
the  practice  of  surgery,  in  which  we  have  to  deal  with  single  cases,  not 
with  many  at  once,  and  in  which  each  case  presents  many  questions 
that  cannot  yet  be  solved  by  general  statements. 

In  deciding  for  or  against  the  removal  of  a  cancerous  breast,  in  any 
single  case,  we  may,  I  think,  dismiss  all  hope  that  the  operation  will  be 
a  final  remedy  for  the  disease.  I  will  not  say  that  such  a  thing  is  im- 
possible ;  but  it  is  so  highly  improbable,  that  a  hope  of  its  occurring  in 
any  single  case  cannot  be  reasonably  entertained. 

The  question,  then,  is,  whether  the  operation  will  add  to  the  length, 
or  to  the  happiness,  of  life.  The  conclusion  from  the  foregoing  tables 
might  be  that  the  length  of  life  would  be  the  same,  whether  the  local 
disease  were  removed  or  not.  But  such  a  conclusion  cannot  be  uncon- 
ditionally adduced  for  the  decision  in  a  single  case.  The  tables  do  not 
include  cases  in  which  the  operation  was  fatal  by  its  own  consequences  : 
yet  these  are  not  few.  In  235  operations  for  the  removal  of  cancerous 
and  other  diseased  breasts,  I  find  23  deaths :  and  probably  this  mor- 
tality of  10  per  cent.|is  not  too  high  an  estimate, — at  least,  for  the  results 
of  hospital  practice.  We  have  to  ask,  therefore,  whether  it  is  probable 
that  the  operation  will  add  to  the  length  or  comfort  of  life,  enough  to 
justify  the  incurring  this  risk  from  its  own  consequences. 

I  cannot  doubt  that  the  answer  may  be  often  affirmative.  1.  In  cases 
of  acute  hard  cancer  the  operation  may  be  rightly  performed :  though 
speedy  recurrence  and  death  may  be  expected,  its  performance  is  justi- 
fied by  the  probability  (see  p.  555)  that  it  will,  in  some  measure,  pro- 
long life,  and  will  save  the  patient  from  dreadful  suff"ering.  2.  On 
similar  grounds,  the  operation  seems  proper  in  all  cases  in  which  it  is 
clear  that  the  local  disease  is  destroying  life  by  pain,  profuse  discharge, 
or  mental  anguish,  and  is  not  accompanied  by  evidences  of  such  cachexia 
as  would  make  the  operation  extremely  hazardous.  3.  In  all  the  cases 
in  which  it  is  not  probable  that  the  operation  will  shorten  life,  a  motive 
for  its  performance  is  afforded  by  the  expectation  that  part  of  the  re- 
mainder of  the  patient's  life  will  be  spent  with  less  suffering,  and  in 
hope,  instead  of  despair ;  for  when  they  are  no  longer  sensible  of  their 
disease,  there  are  few  cancerous  patients  who  will  not  entertain  and 
enjoy  the  hope  of  long  immunity,  though  it  be  most  unreasonable  and 
not  encouraged. 

On  the  other  side,  there  are  many  cases  in  which  the  balance  is  clearly 
against  the  operation.     1.  In  well-marked  chronic  cancers,  especially 


560  SCIRRHOUS    CANCER    OF    THE    BREAST. 

in  old  persons,  it  is  so  little  probable  that  the  operation  will  add  to 
either  the  comfort  or  the  length  of  life,  that  its  risk  had  better  not  be 
incurred.  These  are,  indeed,  the  cases  in  which  the  operation  may  be 
longest  survived ;  but  they  are  also  those  in  which,  without  operation, 
life  is  most  prolonged  and  least  burdened.  2.  In  cases  in  which  the 
cachexia,  or  evident  constitutional  disease,  is  more  than  proportionate 
to  the  local  disease,  the  operation  should  be  refused :  it  is  too  likely  to 
be  fatal  by  its  own  consequences,  or  possibly  by  accelerating  the  pro- 
gress of  cancer  in  organs  more  important  than  the  breast.  On  similar 
grounds,  and  yet  more  certainly,  it  should  not  be  performed  when  there 
is  any  reasonable  suspicion  of  internal  cancer.  3.  If  there  be  no 
weighty  motives  for  its  performance,  the  operation  should  be  avoided 
in  all  patients  whose  general  health  (independently  of  the  cancerous 
diathesis)  makes  its  risk  unusually  great ;  in  all,  for  example,  who  are 
very  feeble,  very  fat,  over-fed,  intemperate,  or  in  any  of  those  condi- 
tions which  make  persons  unfavorable  subjects  for  surgical  operations. 

The  above  rules  leave  unconsidered  a  large  portion  of  the  cases  of 
hard  cancer  of  the  breast ;  and  I  fear  that,  at  present,  no  other  state- 
ment can  be  made  concerning  the  cases  which  do  not  fall  within  such 
rules  as  these,  than  that  each  must  be  decided,  by  weighing  the  proba- 
bility that  the  operation  will  prove  fatal,  or,  by  weakening  the  patient, 
will  accelerate  the  progress  of  the  constitutional  disease,  against  the 
probability  of  its  adding  to  the  comfort,  and  thereby  to  the  length,  of 
life.  The  first  of  these  probabilities  must  be  estimated  by  the  same 
general  principles  (vague  as  they  are)  by  which  we  reckon  the  dangers 
of  all  capital  operations :  the  estimate  of  the  second  may  be,  I  hope, 
assisted,  though  it  cannot  be  settled,  by  the  evidence  collected  in  the 
foregoing  tables.  In  every  case  we  should  keep  in  view  the  twofold 
method  of  destruction  by  this  disease.  It  may  destroy  life  by  its  con- 
sequences as  a  local  disease  ;  or  by  its  primary  and  specific  cachexia, 
which  may  be  progressive  independently  of  the  local  afi"ection.  Usually, 
indeed,  its  local  and  constitutional  parts  mutually  afiect  and  aggravate 
each  other,  and  both  contribute  to  the  fatal  issue  ;  but,  since  they  do 
not  always  contribute  in  the  same  proportions,  our  object  should  be  to 
ascertain,  in  each  case,  which  will  contribute  most, — the  local  disease, 
which  the  operation  can  remedy,  or  the  constitutional,  which,  if  at  all 
affected  by  the  operation,  may  be  made  more  intense. 


MEDULLARY    CANCEE.  561 

LECTURE   XXXI. 

MEDULLA  PvY    CANCEE. 

PART    I. — ANATOMY. 

From  the  long  list  of  names  which  Dr.  Walshe,  with  his  usual  pro- 
found research,  has  found  assigned  to  this  disease,  I  select  that  of  Me- 
dullary Cancer,  because  it  has  been  sanctioned  by  the  longest  usage 
and  by  many  of  the  best  pathologists.  It  is  true  that  the  term  "  medul- 
lary" is  vague  and  unmeaning;  yet  even  this  seeming  defect  may  have 
some  advantage,  since,  after  long  custom,  we  may  now  employ  the 
word,  as  we  do  inflammation,  cancer,  and  many  others,  without  any 
reference  to  their  original  meaning,  and,  therefore,  without  any  danger 
of  too  much  limiting  our  thoughts  to  the  likenesses  which  they  express. 
The  very  precision  and  fixity  of  such  terms  as  encephaloid,  cerebriform, 
cephaloma,  and  the  like,  are  objectionable,  by  directing  the  mind  to  a 
single  character  of  diseased  structures,  and  that  an  inconstant  one ;  for 
the  likeness  to  brain  is  observable  in  only  a  portion  of  the  tumors  to 
which  the  names  of  brain-like  and  its  synonyms  are  applied. 

The  boundaries  of  the  group  of  medullary  cancers  can  be  only 
vaguely  drawn ;  for,  although,  on  the  whole,  and  as  a  group,  they  have 
peculiarities  both  of  structure  and  of  history,  which  sufficiently  distin- 
guish them  from  the  scirrhous  and  other  cancers,  yet,  define  them  by 
whatever  character  we  may,  a  series  of  specimens  might  be  found  filling 
every  grade  between  them  and  each  of  the  other  chief  forms.  The 
term  "soft  cancer,"  often  applied  to  them,  expresses  their  most  obvious, 
though  not  their  most  important,  distinction  from  the  scirrhous  or  hard 
cancers,  and,  used  comparatively,  it  might,  for  the  present,  suffice  for 
the  definition  of  the  group.  But,  in  the  group  thus  defined,  there  are 
included  many  forms  that  appear  widely  different  from  each  other  ;  and 
there  is,  as  Rokitansky  has  well  said,  no  disease  of  which  the  examples 
present  more  deviations  from  any  one  cardinal  character.  It  might  be 
right  to  arrange  the  examples  of  some  of  these  deviating  forms  under 
distinct  titles ;  but,  at  present,  it  may  be  more  useful  to  make  no  other 
division  of  the  group,  than  into  such  as  may  be  called,  respectively, 
soft  Sind  firm  medullary  cancers.  In  any  large  series  of  specimens,  the 
softer  kinds  would  constitute  about  two-thirds,  the  firmer  about  one- 
third,  of  the  whole  number.  The  former  would  include  such  as  are  de- 
scribed as  encephaloid,  brain-like,  milt-like,  pulpy,  placental,  &c.;  the 
latter  would  be  such  as  have  been  called  mastoid,  solanoid,  nephroid, 
apinoid,  &c.* 

*  I  believe,  also,  that  many  examples  of  "  albuminous  sarcoma''  have  been  firm  medul- 
lary cancers. 


562  MEDULLARY    CANCEE. 

Certain  transitional  specimens  would  be  found  in  the  series,  which 
might  be  arranged  in  either  division,  or  between  the  two ;  but  these, 
though  they  may  prove  that  there  is  no  specific  distinction  between  the 
two  chief  divisions,  do  not  invalidate  the  utility  of  speaking  of  them 
separately. 

The  medullary  cancers,  whether  soft  or  firm,  may  grow  either  as  se- 
parable tumors  or  as  infiltrations.  In  the  former  condition,  they  are 
most  frequent  in  the  intermuscular  and  other  spaces  in  the  limbs,  in  the 
testicle,  the  mammary  gland,  and  the  eye:  rarely,  they  are  thus  found 
in  the  bones.  In  the  latter  condition,  they  most  frequently  occupy  the 
substance  of  the  uterus,  the  digestive  canal,  the  serous  membranes,  the 
periosteuni  and  the  bones. 

We  have,  herein,  the  first  point  of  contrast,  in  addition  to  that  of 
their  consistence,  between  the  medullary  and  the  scirrhous  cancers. 
The  latter  are  almost  always  infiltrations  of  natural  parts :  the  former 
appear,  in  nearly  equal  frequency,  as  infiltrations,  or  as  distinct 
growths,  of  cancer-substance. 

The  contrast  is  equally  marked  between  them  in  regard  to  their  re- 
spective seats  and  allocations.  Of  every  100  primary  hard  cancers,  I 
believe  that  not  less  than  95  would  be  found  in  the  breast ;  and  there 
is  no  other  organ  in  which  they  are  not  very  rare.  But,  among  103 
tabulated  instances*  of  medullary  cancer  in  external  parts,  the  seat  of 
primary  disease  was  in  the 

Testicle, in  29  cases. 

Bones  (most  frequently  in  the  femur),       .          .          .         .         .          ,  "  21  " 

Limbs  (especially  in  the  intermuscular  spaces),        .          .         .         .  "  19  " 

Eyeball  or  orbit, "  10  " 

Breast, «  7  cc 

Walls  of  the  chest  or  abdomen,         .         .         .         .         .         .         .  "  5  " 

Lymphatics, «  4  ct 

Various  other  parts,           .         .          ......          .  "  8  " 

103 

Let  me  now,  for  general  examples,  describe  such  soft  medullary  tu- 
mors as  often  occur  in  the  intermuscular  spaces  of  the  limbs  or  trunk. 

To  the  touch  they  present  a  peculiar  softness,  or  a  deceptive  sense 
of  the  slow  fluctuation  of  some  thick  liquid ;  so  that,  even  to  the  most 
experienced,  their  diagnosis  from  collections  of  fluid  is  often  doubtful; 
and  the  achievement  of  experience  in  relation  to  them  is  caution  rather 
than  knowledge. 

In  shape,  these  tumors  are  commonly  round,   oval,   or  spheroidal, 

*  It  need  hardly  be  said  that  this  table,  containing  no  cases  of  medullary  cancer  in  the 
uterus  or  other  internal  organs,  is  not  intended  to  prove  anything  concerning  the  relative 
frequency  of  the  disease  in  each  part  of  the  body.  I  know  no  records  by  which  this  could 
be  proved.  Its  only  purposes  are,  to  show  the  contrast  between  medullary  and  scirrhous 
cancers  in  relation  to  their  usual  seats  in  external  parts,  and  to  indicate  the  kind  of  cases 
from  which  many  of  the  other  tables  in  this  lecture  are  derived. 


GENERAL    STRUCTURE    AND    RELATIONS.  663 

fitting  the  adjacent  parts.  But  they  may  be  variously  lobed ;  and  when 
they  are  so,  these  following  things  may  be  noticed  in  them,  as  well  as 
in  the  firmer  kinds.  (1)  Their  lobes  are  peculiarly  apt  to  extend  into 
muscular  and  other  interspaces,  far  away  from  their  chief  mass.  Thus 
(as  I  have  seen)  in  the  foot,  they  may  track  through  the  interosseous 
metatarsal  spaces,  or  between  bones  of  the  tarsus ;  or,  about  the  hip 
or  knee,  portions  may  extend  deep  down  to  the  immediate  coverings  of 
the  joint ;  or  from  behind  the  ankle-joint,  they  may  reach,  with  the 
flexor  tendons,  far  into  the  sole  of  the  foot.  (2)  Thus  deepening  as 
they  grow,  parts  of  these  tumors  may  acquire  unexpected  deep-seated 
attachments.  It  is  frequent  to  find  them  so  attached  in  the  neck,  even 
when,  in  their  beginning,  they  were  easily  movable  tumors,  or  such  as 
patients  call  "kernels."  (3)  In  the  same  extension,  they  are  much 
more  apt  than  other  tumors  are  to  grow  around,  and  completely  inclose, 
important  vessels  and  nerves.  I  have  thus  seen,  in  one  case,  the  phrenic 
nerve,  in  another  the  pneumogastric,  in  another  the  femoral  artery,  in 
others  the  carotid  artery  and  jugular  vein,  passing  right  through  medul- 
lary cancers  which,  at  first,  appeared  freely  movable  and  not  deeply 
fixed,  and  even  now  had  no  characters  of  infiltration. 

The  parts  around  a  separable  medullary  cancer  are  generally  only 
extended,  as  they  might  be  around  an  innocent  tumor.  They  are  usually 
not  contracted,  or  adherent,  as  those  next  to  a  hard  cancer  are.  Even 
such  a  tissue  as  the  glandular  substance  of  the  testicle  may  be  cleanly 
separated  from  the  surface  of  a  medullary  cancer,  around  which  it  has 
been  stretched.  Sometimes,  however,  the  parts  near  the  principal  tu- 
mor contain  smaller  detached  growths ;  and  more  rarely  they  are  infil- 
trated with  cancer. 

When  a  distinct  capsule  exists  around  a  medullary  cancer,  it  is 
usually  com-posed  of  connective  tissue,  forming  a  very  thin  layer,  from 
the  interior  of  which  partitions  may  pass,  intersecting  the  substance  of 
the  tumor,  or  investing  its  several  lobes.  Generally,  such  a  capsule 
contains  numerous  tortuous  bloodvessels ;  and  is  tensely  filled,  so  that, 
as  soon  as  it  is  cut,  the  tumor  protrudes,  or,  when  very  soft,  oozes  out, 
like  a  thick  turbid  fluid.  It  is,  usually,  easy  to  separate  the  capsule, 
or  part  of  it,  from  the  surrounding  tissues  ;  but  it  may  be  closely  ad- 
herent, and,  I  think,  generally  is  so  in  the  cases  of  medullary  cancers 
in  the  breast. 

In  section,  the  soft  medullary  cancers  usually  appear  lobed  ;  and  the 
partitions  between  the  lobes,  derived  from  the  investing  capsule,  are 
often  so  complete  that  they  may  appear  like  separate  cysts  filled  with 
endogenous  growths.  The  lobes  are  of  various  sizes  and  shapes, 
through  mutual  compression,  and  they  may  even  seem  very  difi"erently 
constructed. 

The  material  composing  these  cancers  (when  not  disordered  by  the 
effects  of  hemorrhage,  inflammation,  or  other  disease)  is  a  peculiar,  soft, 
close-textured  substance,  having  very  little  toughness,  easily  crushed 


564  SOFT  MEDULLARY  CANCER. 

and  spread  out  hj  compression  with  the  fingers.  It  is  very  often  truly 
brain-like,  most  like  foetal  brain,  or  like  adult  brain  partially  decom- 
posed and  crushed.  Many  specimens,  however,  are  much  softer  than 
brain  ;  and  many,  though  of  nearly  the  consistence  of  brain,  are  unlike 
it,  being  grumous,  pulpy,  shreddy,  or  spongy,  like  a  placenta,  with  fine 
soft  filaments.  Very  few  have  a  distinct  appearance  of  fibrous  or  other 
regular  structure. 

In  color,  the  material  may  be  white,  but  most  commonly,  when  the 
cancer  is  fresh,  it  is  light  gray  (like  the  grayness  of  the  retina  after 
death).  The  tint  is  usually  clear ;  it  is  in  many  cases  suffused  with 
pale  pink  or  lilac,  or  with  a  deeper  purple  ;  and,  in  nearly  all,  is  varie- 
gated with  eifused  blood  and  full  bloodvessels,  whose  unequal  abun- 
dance in  different  parts  of  the  tumor  produces  a  disorderly  mottled  ap- 
pearance. Masses  of  bright  red  or  ochrey  substance  also,  like  tubercle, 
are  often  found  in  or  between  the  lobes,  as  if  compressed  by  them,  while 
withering  and  drying  in  the  midst  of  their  growth. 

When  pressed  or  scraped,  the  soft  medullary  cancers  yield  abundant 
"cancer-juice,"  a  milky  or  cream-like,  or  some  other  turbid,  material, 
oozing  or  welling  up  from  their  pressed  mass.  There  is  no  better  rough 
test  for  the  diagnosis  of  medullary  cancers  than  this  is;  and  the  sub- 
stance thus  yielded  is  generally  diffusible  in  water,  making  it  uniformly 
turbid,  not  floating  in  coarse  shreds  or  fragments. 

When  the  greater  part  of  the  softer  and  liquid  substances  are  thus 
pressed  out,  there  remains  a  comparatively  small  quantity  of  tissue, 
which  appears  filamentous,  with  abundant  bloodvessels,  and,  to  the 
naked  eye,  is  spongy  and  fiocculent,  like  the  tissue  of  a  placenta.  This 
is  the  so-called  "  stroma"  of  the  cancer;  and  it  differs  from  that  which, 
in  the  hard  cancers,  has  been  so  named  (p.  531),  in  that  it  is  not  part 
of  the  tissue  in  which  the  cancer  has  its  seat,  but  is  probably  formed 
during  the  growth  of  the  cancer,  and  is  as  truly  part  of  the  cancer  as 
the  cells  and  other  corpuscles  are. 

Such  are  the  most  general  or  normal  characters  of  the  soft  medullary 
cancers.  It  would  be  vain  to  attempt  to  describe  all  the  varieties  to 
which  they  are  subject  by  the  mingling  of  cysts  within  or  on  the  sur- 
face of  their  mass  ;  by  hemorrhage  into  their  substance  ;  by  inflamma- 
tion ;  and  by  the  various  degenerations  of  their  proper  substance,  of 
the  extravasated  blood,  and  of  the  inflammatory  products.  There  are, 
I  think,  no  other  examples  in  which  the  diseases  of  the  products  of  dis- 
ease are  so  frequent,  so  various,  or  so  confusing  as  in  these. 

It  is  in  the  medullary  cancers  alone  that  the  bloodvessels  have  been 
minutely  studied;  and  in  these  alone  that  it  is  easy  to  distinguish  the 
vessels  of  the  cancer  itself  from  those  of  the  organ  in  which  it  is  seated. 
M.  Lebert  and  his  colleagues  have  made  numerous  injections,  display- 
ing arteries,  capillaries,  and  veins,  arranged  in  networks  of  various 
closeness,  in  the  substance  of  medullary  cancers  of  the  ovary,  omentum, 
uterus,  and  other  parts.     They  have  thus  disproved  the  belief  that  the 


VASCULARITY.  565 

vascular  system  of  these  tumors  is  exclusively  either  arterial  or  venous. 
I  may  add,  that  the  minute  bloodvessels,  though,  in  proportion  to  their 
size,  they  are  thin-walled  and  easily  torn,  have  the  same  structures  as 
those  in  other  new-formed  parts.* 

In  some  medullary  tumors  we  may  notice  a  remarkable  abundance  of 
even  large  bloodvessels.  Next  to  the  proper  cancer-corpuscles,  they 
may  appear  to  be  the  chief  constituent.  The  cancer  that  contains  them 
may  thus  appear  in  many  respects  like  an  erectile  tumor,  and  may  often 
vary  in  size  according  to  the  fulness  of  its  bloodvessels.  (See  p.  576, 
note.)  When  the  bloodvessels  are  chiefly  arterial  the  whole  mass  of  the 
tumor  may  have  a  soft,  full  pulsation — a  condition  which  seems  pecu- 
liarly apt  to  be  found  when  the  tumor  is  in  part  imbedded  in,  or  sup- 
ported by,  bone,  and  in  part  held  down  by  fibrous  tissue,  such  as  that 
of  the  periosteum. t 

To  the  same  abundant  vascularity  of  these  tumors  we  may  ascribe 
not  only  their  liability  to  internal  apoplectic  hemorrhage, |  but  the 
great  bleedings  that  may  ensue  when  they  protrude  through  ulcers,  or 
are  wounded.  I  have  twice  seen  the  difBculty  of  distinguishing  a 
medullary  cancer  of  the  testicle  from  an  hsematocele  enhanced  by  the 
fact,  that  when  the  swelling  was  punctured  with  a  trocar,  blood  flowed 
in  a  full  stream  through  the  canula,  and  continued  so  to  flow  till  the 
canula  was  withdrawn.  The  size  of  the  swelling  was  not  diminished,  as 
that  of  an  hsematocele  would  have  been,  by  the  abstraction  of  the  blood ; 
and  in  both  cases  it  proved  to  be  a  large  medullary  cancer,  very  vascu- 
lar and  very  soft.  So,  when  such  tumors  are  cut  into  in  the  limbs,  the 
vessels  that  bleed  are  far  larger  and  more  numerous  than  in  any  other 
tumor,  except  the  erectile. 

The  vessels,  moreover,  often  appear  defective  in  muscular  power ; 
for,  as  Mr.  Hey§  noticed,  the  bleeding  from  them  scarcely  decreases 
even  when  a  tourniquet  compresses  the  main  artery  of  the  limb.  It  is 
as  if  they  could  not  contract  so  as  to  close  themselves,  even  when  the 
force  of  the  blood  is  diminished  to  the  amount  with  which  it  traverses 
the  anastomosing  channels.  Lastly,  we  may  connect  with  the  great 
vascularity  and  rapid  growth  of  these  soft  tumors,  the  large  size  of  the 
veins  near  them ;  though  this  is  not  peculiar  to  them,  but  is  found,  1 
think,  with  nearly  all  tumors  that  grow  rapidly  and  to  a  large  size. 

Lymphatics  have  been  injected  in  two  specimens  of  medullary  cancer 

*  Dr.  WesthofF,  in  a  thesis  "  Mikrosk.  Onderzockingen  over  de  Ontaarding  von  Aderen 
en  Zemuven  in  Ranker,"  1860,  which  is  analyzed  in  the  Dublin  Quarterly  Jonrn.,  Nov., 
1860,  makes  it  probable  that  the  impossibility  of  injecting  veins  in  some  cancers  is  due  to 
their  being  filled  with  cancerous  matter,  which  stops  the  injection  after  it  has  traversed  the 
capillaries. 

f  See  Mr.  Stanley's  paper  on  the  "Pulsating  Tumors  of  Bone,''  in  the  Med.-Chir.  Trans., 
vol.  xxviii,  p.  303. 

J  It  is  chiefly  to  the  medullary  tumors,  changed  by  internal,  and  prone  to  external, 
hemorrhage,  that  the  name  of  fungus  hsematodes  has  been  applied. 

§  Observations  in  Surgery,  p.  258. 


566         MEDULLARY    CANCEROUS    INFILTRATION    OF    BONE. 

of  the  Stomach  and  of  the  liver,  by  Schroeder  van  der  Kolk.*  In  both 
instances  the  vessels  passed  into  the  very  substance  of  the  cancer.  Of 
nerves,  I  believe  that  none  have  been  found  in  these  or  in  any  other 
cancers,  except  such  as  they  have  involved  in  their  growth. 

The  same  structures  which  alone  form  the  separable  medullary  can- 
cers may  be  infiltrated  among  the  natural  structures  of  parts.  Thus 
infiltrated,  the  natural  structures  are  expanded  and  rarefied ;  some- 
times, indeed,  they  seem  to  be,  in  a  measure,  thus  changed,  even  before 
the  cancerous  material  is  deposited  among  them.f  Finally,  most  of 
them  disappear,  as  in  the  infiltrations  of  scirrhous  cancer ;  and  the 
cancerous  mass  may  now  seem  like  a  separately  growing  tumor ;  or, 
when  its  material  is  very  soft,  it  may  appear  as  a  quantity  of  creamy 
liquid,  collected  like  the  pus  of  an  abscess,  in  a  defined  cavity. 

Exceptions  to  the  general  rules  of  the  wasting  of  the  infiltrated  tis- 
sues are  often  observed  in  the  fibrous  tissues  and  the  bones ;  both  these 
may  increase  during  soft  cancerous  infiltrations. 

Medullary  cancers  may  be  found  in  the  articular  ends  of  bones,  form- 
ing distinct  tumors,  around  which  the  walls  of  the  bone  are  expanded  in 
a  thin  or  imperfect  shell.  But  more  commonly  the  cancer  is  infiltrated. 
In  these  cases,  it  usually  occupies,  at  once,  the  cancerous  tissue,  the 
wall  of  the  bone,  and  the  periosteum :  and  it  seems  probable  that  the 
disease  begins  simultaneously  in  all  these  parts ;  or,  at  least,  that  when 
they  are  affected  in  succession,  it  is  not  generally  by  extension  from 
one  to  the  other.  Hence  we  commonly  find  that  a  tumor  surrounds  the 
bone,  or,  in  the  case  of  a  flat  bone,  covers  both  its  surfaces ;  and  that 
the  portion  of  bone  thus  invested  is  itself  infiltrated  with  cancer,  which 
is  collected  most  evidently,  but  not  exclusively,  in  its  cancellous  tissue. 
When  a  medullary  tumor  thus  surrounds  a  long  bone,  it  is  usually  of 
unequal  thickness :  when  both  surfaces  of  a  flat  bone  are  covered  the 
tumor  is  usually  biconvex  lens-shaped,  and  is,  on  both  surfaces,  of 
nearly  equal  extent. 

The  periosteum  may  seem  to  be  continued  over  a  medullary  cancer 
thus  placed ;  but  is  really,  with  the  exception  of  a  thin  outer  layer,  in- 
volved in  it,  and  intersects  its  substance.  The  intersecting  portions  of 
periosteum  chiefly  traverse  the  exterior  tumor,  extending  from  the  layer 
which  invests  its  surface  to  the  wall  of  the  bone.  They  form  branching 
and  decussating  shining  bands,  which  to  the  microscope  present  a  per- 
fect fibrous  tissue,  infiltrated  with  the  cancerous  materials.  They  may, 
also,  be  much  increased  by  growth,  so  as  to  give  the  section  of  the 
tumor  an  appearance  of  "  grain,"  or  of  a  tissue  with  fibres  set  vertically 
on  the  bone.  Or,  the  periosteal  tissue  thus  growing  may  ossify.  In 
this  event,  it  forms,  in  a  large  majority  of  cases,  a  light,  spongy,  and 
friable  growth  of  bone,  which  is  like  an  internal  skeleton  of  the  cancer. 

Most  of  the  specimens  of  "  spongy"  or  "  fungous"  exostoses  are  such 

*  Lespinasse:  De  vasis  novis  pseudomembranarum,  1842,  p.  41. 
f  Walshe,  1.  c,  p.  555. 


MEDULLARY    CANCEROUS    INFILTRATION    OF    BONE.  567 

skeletons  of  cancers,  examined  after  the  maceration  and  removal  of  all 
the  morbid  structures  that  filled  their  interspaces.  The  new  bone  is 
often  formed  in  thin  plates  and  bars  or  fibres,  the  chief  of  which  extend 
outwards,  at  right  angles  to  the  surface  of  the  bone  on  which  they  grow  ; 
they  may  pass  deeply  into  the  substance  of  the  cancer,  but  they  seldom 
reach  its  outer  surface  :  no  medulla  is  formed  with  them  ;  and  they 
sometimes  form  a  denser  and  harder  tissue,  like  that  which  belongs  to 
the  osteoid  cancers  (see  p.  483). 

In  the  walls,  or  compact  substance,  of  the  bone  thus  inclosed  by  can- 
cer, it  is  common  to  find  the  laminae  separated  by  cancerous  deposit, 
mingled  with  a  ruddy,  soft  material  like  diploe.  In  other  cases,  the 
structure  of  the  walls  is  rarefied,  and  converted  into  a  light,  soft,  and 
porous  or  finel}''  spongy  tissue,  whose  spaces  contain  cancer-structures. 
The  Haversian  canals,  also,  may  be  enlarged ;  cancerous  matter  being 
formed  within  them.  Sometimes,  a  peculiar  appearance  is  derived  from 
an  unequal  separation  of  the  laminse  of  a  bone's  walls ;  large  spaces 
being  found  between  them,  like  cysts,  which  may  be  filled  with  blood 
or  softened  cancer. 

Lastly,  in  the  diploe  or  cancellous  tissue,  a  corresponding  state  exists. 
The  soft  cancerous  material  excludes  the  medulla,  and,  commonly,  its 
formation  is  attended  with  a  disturbed  growth  of  the  bony  cancelli,  so 
that  they  form  a  finely  spongy,  dry  and  brittle  structure,  or  more  rarely 
a  dense  and  hard  structure,  resembling  the  skeleton  of  the  external  mass 
of  cancer.* 

It  remains  that  I  should  describe  the  Firm  Medullary  Cancers. 

In  all  their  general  relations, — as  to  seat,  shape,  size,  and  connec- 
tions,— these  correspond  with  the  softer  kind.  Like  them,  they  may  be 
separate  masses  or  infiltrated;  may  have  distinct  investing  capsules,  or 
may  extend  indefinitely  in  the  proper  substance  of  organs ;  like  them, 
they  are  apt  to  afi"ect  a  certain  part  or  place  rather  than  a  single  tissue  : 
or  may  be  the  seats  of  various  degeneration  or  disease  :  their  only  pecu- 
liarities are  in  their  own  structures. f 

They  are  firm  masses :  not  hard,  like  scirrhous  cancers ;  but  firm, 
elastic,  tense,  compact,  and  moderately  tough ;  they  are  as  tough  as 
the  more  pliant  examples  of  fibrous  cartilage,  and  merge  into  exact 
likeness  to  the  less  hard  and  more  elastic  scirrhous  cancers.  They  are 
not  evidently  fibrous,  but  tear  or  split  as  very  firm  coagulated  albumen 
might.  Their  cut  or  torn  surfaces  appear  peculiarly  smooth,  compact, 
shining,  and  sometimes  translucent ;  in  some  instances  thej  are  uni- 
form and  without  plan ;  in  some,  more  regularly  and  minutely  lobed, 

*  I  have  twice  seen  a  formation  of  very  firm  fibrous  substance,  lilve  the  basis  of  the  osteoid 
cancers,  in  the  cancellous  tissue  of  bones  that  w^ere  surrounded  with  very  soft  medullary 
cancer.  I  have,  also,  seen  a  light  brittle  skeleton  formed  in  the  cancer  external  to  a  bone, 
of  which  the  cancellotis  tissue  was  converted  into  hard  osteoid  substance. 

f  Generally,  I  think,  when  they  affect  bones,  the  osseous  tissue  is  apt  to  soften  and 
waste,  rather  than  to  grow  as  it  does  in  the  soft  medullary  cancerous  afiections.  Certainly, 
the  firm  medullary  cancers  rarely  have  internal  skeletons. 


568         MEDULLAEY   CANCER  —  MICROSCOPIC    STRUCTURE. 

or  even  imitating  the  appearance  of  any  gland,  such  as  the  mammary 
or  parotid,  in  which  they  lie.  Sometimes  they  present  a  strongly 
marked  grain,  as  if  from  fibres  :  but  this  results,  I  believe,  from  a 
peculiar  fasciculate  and  linear  arrangement  of -elongated  cells. 

In  color,  the  firm  medullary  cancers  are  hardly  less  various  than  the 
softer  kind.  They  may  be  pure  white ;  but  more  often  are  white, 
tinted  or  streaked  with  pale  pink,  or  yellow ;  or  they  may  be  in  nearly 
every  part  buif-colored,  or  gray  ;  or  these  tints  may  be  mingled  and 
mottled  with  blood- color,  though  not  so  deeply,  or  with  such  eifusions  of 
blood,  as  are  frequent  in  the  softer  tumors. 

On  pressure,  especially  after  contact  with  water,  they  generally 
yield  a  characteristic  creamy  or  grayish  fluid,  which  sometimes  appears 
strangely  abundant,  considering  their  firmness  of  texture.  In  a  few 
instances,  however,  this  character  is  wanting  ;  the  firmest  tumors  may 
give  only  a  thin  turbid  fluid. 

Among  the  points  of  contrast,  in  the  descriptions  of  medullary  and 
scirrhous  cancers,  is  the  wider  range  of  variety  exhibited  by  the  former 
in  the  original  characters  of  its  growth.  For  the  diversities  which  I 
have  been  describing  are  not  to  be  referred  to  changes  ensuing  in  differ- 
ent stages  of  the  same  disease ;  the  firmer  cancers  do  not  gradually 
become  soft,  nor  the  soft  become  firmer  ;  they  are  not  to  be  connected 
(as  the  chief  varieties  of  scirrhous  cancer  may  be)  with  the  acute  or 
chronic  progress  of  the  disease,  or  with  its  different  modes  of  growth, 
or  with  the  differences  of  age  in  which  it  occurs  ;  rather,  the  peculiar 
features  of  each  specimen,  and  of  each  chief  group,  appear  to  be  original 
and  constant, — provided  they  are  not  affected  by  degeneration  or  disease. 
I^ow,  equal  diversities  exist  in  the  microscopic  structures  of  medullary 
cancers.  There  are,  indeed,  certain  characters  to  which  nearly  all  are 
conformed  :  the  microscopic  diagnosis  is,  therefore,  seldom  difficult,  very 
seldom  doubtful ;  yet  many  varieties  of  appearance  need  to  be  learnt, 
both  that  the  disease  may  be  always  recognized,  and  that  we  may,  if 
possible,  hereafter  accurately  divide  the  inconveniently  large  group 
into  smaller  ones.  At  present  such  a  division  is  impracticable  ;  for  we 
can  only  sometimes  trace  a  correspondence  between  a  peculiarity  of 
microscopic  structure,  and  one  of  general  aspect,  in  the  tumors  ;  but  it 
should  be  a  chief  object  of  future  inquiries. 

The  varieties  exist  in  both  the  corpuscles  and  the  basis,  stroma,  or 
intercellular  substance  of  the  cancer. 

Among  the  corpuscles,  the  most  frequent,  and  that  which  seems  the 
normal,  form,  is  that  of  nucleated  cells,  which,  in  all  essential  charac- 
ters, are  like  those  of  hard  cancer  (p.  526,  Fig.  85).  Examples  of  such 
cells  may  be  found  in  nearly  every  specimen,  although,  in  certain  in- 
stances, other  forms  may  predominate  over  them.  There  is,  I  believe, 
no  mark  by  which  they  may  be  always  distinguished  from  the  cells  of 
hard  cancers.  They  may  be  softer,  less  exactly  defined,  more  easily 
disintegrated  by  water,  flatter  than  the  cells  of  scirrhous  cancer  are, 


MEDULLARY    CANCER  —  MICROSCOPIC    STRUCTURE.      569 


but  thei-e  is  in  these  things  no  important  distinction.  The  only  con- 
stant difference  is  in  the  modes  of  compacting,  and  in  the  relations  of 
the  cancer-materials  to  the  natural  structures  in  which  they  are  placed. 
Cells  such  as,  in  scirrhous  cancers,  are  closely  placed,  with  a  sparing, 
firm,  intermediate  substance,  or  are  tightly  packed  among  the  contracted 
structures  of  a  mammary  gland,  are  in  the  medullary  cancers  more 
loosely  held  together,  in  a  more  abundant,  and  much  softer  or  liquid 
intercellular  substance. 

The  chief  varieties  of  microscopic  forms  in  medullary  cancers  may 
be  described  as  affecting,  severally,  the  nuclei,  the  cells,  and  the  inter- 
cellular substance  ;  and  it  may  be  generally  understood  that  each  pecu- 
liar form  may  occur  in  combination  with  a  predominant  quantity  of  the 
ordinary  or  typical  cancer-structures,  or  may,  in  rarer  instances,  form 
the  greater  part,  if  not  the  whole,  of  a  cancerous  mass. 

(a)  Free  nuclei,  suspended  in  liquid  or  imbedded  in  a  soft,  nebulous, 
or  molecular  basis-substance,  may  compose  the  whole  of  a  very  soft 
medullary  cancer.  Appearances  of  cells  may  be  seen  among  them,  be- 
cause of  the  adhesion  of  the  basis-substance  to  them  ;  and  appearances 
of  many-nucleated  cells,  when  fragments  of  the  basis  are  detached  in 
which  several  nuclei  are  imbedded.  But  certainly,  in  many  instances, 
formed  cells  are  rare  or  absent. 

The  nuclei  (Fig.  90)  are  like  those  of  the  typical  cancer-cells  (p.  526)  ; 
they  are  oval  or  round  oval,  having  a  long  dia- 


meter of  from  2  5*0  0^^^0  2oi;o^^^  of  an  inch,  bright. 


Fio-.  90.* 


pellucid,   perfectly   defined,   largely,   and    often 
doubly  nucleolated. 

It  is  in  the  structures  thus  formed  that  the 
minute  bloodvessels  of  cancer  may  be  best  ex- 
amined without  injection ;  for  the  soft  material 


Fig.  91. t 


^^^^^ 
in  which  they  ramify  may  be  washed  aAvay  from     ^^^^^^!3^' 
them,  so  as  to  leave  them   nearly  alone,  and  fit      ^"*' ' 
for  examination  as  transparent  objects. 

[b)  Free  nuclei  (Fig.  91),  which  may  be  considered  as  grown  or  de- 
veloped, are  often  mixed,  in  various  propor- 
tions, with  other  cancer-structures.  Some, 
retaining  the  usual  shape,  are  much  larger 
than  the  average :  others,  rarer  and  more 
peculiar,  are  elongated,  narrow,  strip-like, 
caudate,  or  pyriform.  Some  of  these  are 
very  small,  slender,  and  apparently  of  simple 
structure :  others  more  nearly  acquire  the 
size  and  other  characters  of  cells.  Their 
contents   are   not   so  simple  and  pellucid  as 

■^  Fig.  90.    Nuclei  of  soft  medullary  cancer,  imbedded  in  a  molecular  basis-substance, 
without  cancer-cells.     Magnified  500  times. 

f  Fig.  91.     Various  grown  and  developed  nuclei  of  medullary  cancer,  as  described  in  the 
text.     Magnified  500  times. 

37 


570 


MEDULLARY    CANCER  —  MICROSCOPIC    STRUCTURE. 


those  of  ordinary  nuclei ;  in  the  smaller  they  are  darkly  dotted  or 
granular,  but  no  contained  particles  appear  larger  than  common  nu- 
cleoli. In  others,  larger,  oval,  pellucid  corpuscles,  like  small  nuclei, 
are  contained ;  and  these  seem  to  be  formed  by  the  enlargement  of  the 
nucleoli,  which  thus  approach  or  attain  the  characters  of  nuclei,  while 
the  nuclei  that  contain  them  are  advanced  to  the  condition  of  cells. 
Most  commonly,  the  cells,  that  thus  seemed  formed  out  of  nuclei,  are 
singly  nucleated ;  but  two  or  three  nuclei  are  found  in  a  few  of  large 
size. 

(c)  In  a  few  specimens  of  medullary  cancer  of  the  breast  (p.  577), 
and  of  the  parotid.  I  have  found  the  chief  constituent  to  be  free  or  clus- 
tered nuclei,  of  round  or  round  oval  shape  (Fig.  92)  from  tb^oo^^i  ^o 
^._j_.^th  of  an  inch  in  diameter,  well-defined,  but  not  darkly,  nebulous  or 
molecular  rather  than  pellucid,  and  appearing  to  contain  four,  five, 
or  more  shining  granules,  but  no  special  or  distinct  nucleolus.     They 


Fig.  92* 


Pig.  93.1 


might  have  been  taken  for  large  corpuscles  of  inflammatory  lymph,  but 
that  neither  water  nor  acetic  acid  afl"ected  them.  They  were  imbedded 
in  a  small  quantity  of  molecular  basis,  and  sometimes  arranged  in 
groups,  imitating  the  shapes  of  acini  of  glands.  A  few  of  smaller  size 
but  similar  aspect  appeared  to  be  within  cells. 

[d)  In  a  remarkable  case,  lately  at  St.  Bartholomew's  Hospital,  a 
woman,  67  years  old,  had  two  very  large  and  several  smaller  tumors 
connected  with  the  skull,  a  tumor  in  the  lower  part  of  the  neck,  and 
similar  small  growths  in  the  lungs.  They  were  all  very  soft,  close- 
textured,  white,  or  variously  colored  with  extravasated  blood,  inclosing 
large  cavities  filled  with  bloody  fluid.  Except  that  they  yielded  no 
creamy  fluid  till  after  they  were  partially  decomposed,  one  could  not 
hesitate  to  call  them  medullary  cancers.  But  they  were  composed, 
almost  exclusively,  of  round,  shaded  nuclei,  with  three  or  four  minute 
shining  particles,  and  in  general  aspect  very  like  the  dotted  corpuscles 
of  the  spleen.  Many  of  these  were  free ;  but  more,  I  think,  were  ar- 
ranged in  regular  clusters  or  groups   of  from  five  to  twenty  or  more, 

*  Fig.  92.  Dotted  nuclei  of  medullary  cancer,  described  in  the  text.  Magnified  500 
times. 

f  Fig.  93.  Clustered  nuclei  of  a  medullary  cancer,  described  in  the  text.  Magnified 
about  400  times. 


MEDULLARY    CANCER MICROSCOPIC     STRUCTURE.       571 


Fig.  94.* 


composing  round,  or  oval,  or  cylindriform  bodies  (Fig.  93).  A  few 
similar  nuclei  were  inclosed  singly  in  cells  in  the  cancerous  growths  in 
the  lungs. 

Such  are  the  chief  varieties  in  the  nuclei  of  medullary  cancers. 
Scarcely  less  may  be  found  in  cells,  mingled,  let  me  repeat,  in  diverse 
proportions,  with  cells  or  nuclei  of  typical  form,  and  rarely  surpassing 
them  in  number. 

(e)  Besides  those  varieties  in  the  shapes  of  cells,  which  were  described 
among  the  microscopic  characters  of  hard  cancers  (p.  526),  and  which 
aije  equally,  or  with  yet  more  multiformity,  found  in  these,  we  may 
note  the  occasional  great  predominance  of  elongated  caudate  cells  in 
some  examples  of  medullary  cancers.  I  have  hitherto  observed  this  in 
none  but  some  of  the  firmer  specimens  of  the  kind.  Many  such  contain 
only  typical  cancer-cells ;  but  in  some  the  caudate  and  variously  elon- 
gated cells  predominate,  and,  by  their  nearly  parallel  and  fasciculate 
arrangement,  give  a  fibrous  appearance  to  the  section  of  the  tumor. 
The  adjacent  sketch  (Fig.  Oi)  is  from  the 
cells  of  a  very  firm  tumor  that  grew  round 
the  last  phalanx  of  a  great  toe.f  Its  can- 
cerous nature  was  proved  not  only  by  its 
structure,  but  by  its  recurrence  after  am- 
putation, and  by  similar  secondary  disease 
of  the  inguinal  glands.  I  found  scarcely 
any  cells  but  such  as  are  drawn.  Some 
were  narrow,  tongue-shaped,  broad,  and 
rounded  or  truncated  at  one  end,  and  at 

the  other  elongated  and  tapering.  Some  were  elongated  at  both  ends ; 
some  oat-shaped ;  some  very  slender,  with  long  awn-shaped,  or  cloven 
processes.  All  these  had  large,  oval,  well-defined,  clear  nuclei,  like 
those  of  ordinary  cancer-cells,  and  with  distinct  nucleoli.  Their  tex- 
ture, also,  appeared  to  resemble  that  of  common  cancer-cells ;  they 
differed  only  in  shape,  being,  in  this,  most  like  the  cells  of  recurring 
fibrous  tumors  (p.  512). 

(/)  In  two  instances,  I  have  found  cancers  which,  by  their  general 
characters  and  history,  should  be  called  firm  medullary  cancer,  and 
which  were,  in  great  part,  composed  of  much  smaller,  narrower,  and 
proportionally  more  elongated  cells  than  those  last  described.  One  of 
these  was  a  large  deep-seated  tumor  behind  the  inner  ankle  and  in  the 
sole  of  the  foot,  inclosing  the  posterior  tibial  and  plantar  vessels  and 
nerve,  and  the  flexor  tendons.  In  the  other  case,  the  primary  tumor 
involved  the  gum  and  larger  part  of  the  front  of  the  lower  jaw ;  and 
similar  secondary  disease  was  diffused  through  part  of  the  right  lobe  of 
the  thyroid  gland,  and,  in  small  masses,  in  both  lungs.    All  the  tumors 

*  Fig.  94.     Caudate  and  variously  elongated  cells  of  a  firm  medullary  cancer,  described 
in  the  text.    Magnified  450  times. 

f  Mus.  Coll.  Surg.,  252  ;  and  of  St.  Bartholomew's,  Series  xxxv,  No.  54. 


572  MEDULLARY    CANCER MICROSCOPIC     STRUCTURE. 

were  very  firm  and  elastic ;  the  fluid  that  they  yielded  was  not  creamy, 
but  viscid  and  yellowish.     The  tumor  on  the  foot 
^^"     ■  was  gray,  shining,   minutely  lobed,   intersected 

with  opaque-white  fibrous  bands,  and  in  its  own 
tissue  ajDpeared  fibrous.  That  on  the  jaw  was 
grayish-white,  suffused  with  pink,  glistening,  but 
with  no  appearance  of  fibrous  or  other  texture. 
In  all  there  were  much  molecular  matter  and 
granular  ddbris,  cancer-nuclei,  and  a  few  cells  of 
ordinary  form ;  but  their  essential  structures 
were  (as  in  Fig.  95)  very  small,  narrow,  and 
elongated  cells  and  nuclei.  The  cells  were  of 
various  shapes ;  some  sharply  caudate,  some  swollen  in  the  middle, 
some  abruptly  truncated.  They  looked  wrinkled  and  very  pellucid. 
They  measured,  generally,  about  yo'^oth  of  an  inch  in  length.  Some 
had  elongated  clear  nuclei ;  in  others  no  nuclei  appeared.  Many  free 
nuclei  had  the  same  shapes  as  these  cells,  and  of  many  corpuscles  it 
was  hard  to  say  whether  they  should  be  called  cells  or  nuclei.  "  '; 

{g)  Sometimes  one  meets  with  cells,  in  medullary  cancers,  in  which 
nuclei  are  not  at  first  discernible.  They  are  round,  large,  nebulous ; 
they  contain  many  minute  granules ;  and,  when  water  is  added,  it  dif- 
fuses their  contents,  and  may  display  a  round  nucleus,  smaller,  and 
more  nebulous  or  granular  than  those  of  the  typical  cancer-cells. 

(A)  Cells  containing  many  nuclei  are  regarded  by  some  as  frequent 
in  certain  medullary  cancers.  I  believe  that  such  cells  may  occur,  and 
that  occasionally  endogenous  cells  may  be  found  Avithin  those  of  larger 
size  and  probably  older  growth :  but  I  am  more  sure  that  cells  contain- 
ing cells,  or  containing  more  than  three  nuclei,  are  rare,  at  least  in  me- 
dullary cancers,  occurring  in  external  parts.  I  must  believe,  from  the 
reports  of  others,  that  they  are  more  frequent  in  cancers  of  internal 
organs. t  What  have  been  described  as  brood-cells  in  medullary  can- 
cers, or  as  cells  which,  by  the  multiplication  of  their  nuclei,  were  effect- 
ing rapid  increase  of  the  cancer,  were,  I  believe,  in  some  instances,  the 
many-nucleated  cells  of  myeloid  tumors,  and,  in  more  instances,  de- 
tached masses  or  fragments  of  molecular  basis-substance,  in  which  nu- 
clei were  imbedded.  I  may  add,  that  I  have  not  found,  in  medullary 
cancers,  any  structures  similar  to  those  of  the  laminated  cysts  or  cap- 
sules which  occur  in  epithelial  cancers. 

Such  are  the  chief  varieties  of  the  corpuscles  of  medullary  cancer : 
these,  at  least,  are  what  I  have  found  them  presenting  in  their  natural 
state.  Much  might  be  said  respecting  the  changes  effected  in  them  by 
the  fatty  and  other  degenerations  and  diseases,  and  about  the  confusion 
brought  into  the  microscopic  diagnosis  by  the  granular  masses,  free 
granular  matter,  and  various  debris  hence  derived.     But  for  these  I 

*  Fig.  95.     Small  elongated  cells  and  nuclei,  with  nuclei  of  ordinary  shape,  from  a  firm 
medullary  tumor,  as  described  above.     Magnified  .500  times, 
y  Rokitansky  delineates  some  (Ueber  die  Cyste,  figs.  9,  10,  11). 


MEDULLARY    CANCER MICROSCOPIC    STRUCTURE.       573 

must  refer  to  the  last  lecture,  and  to  the  general  account  of  degenera- 
tions already  given.*  It  remains  that  I  should  speak  of  the  substance 
with  which  the  cells  are  associated, — the  basis,  intercellular  substance, 
or  stroma. 

I  need  not  repeat  what  has  been  said  (p.  531)  respecting  the  "stroma," 
so-called,  of  a  cancerous  infiltration, — that  it  is  only  the  tissue  of  the 
organ  in  which  the  cancer  is  seated.  What  I  have  now  to  describe  is 
the  substance  which  is  proper  to  the  cancer,  and  in  which  the  cancer- 
corpuscles  are  suspended  or  imbedded. 

{a)  The  cells  and  nuclei  of  medullary  cancers  may  be  suspended  in 
liquid  alone ;  and  the  two,  like  a  collection  of  fluid  rather  than  like  a 
tumor,  may  be  infiltrated  in  tissues,  or,  more  rarely,  may  be  contained 
in  small  cavities.  This  is  not  unfrequently  the  case  in  very  rapid  pro- 
ductions of  cancerous  matter,  especially  in  secondary  deposits.  The 
liquid  (cancer-serum,  as  it  has  been  named)  is  turbid ;  it  dims  trans- 
mitted light,  and  has  a  finely  molecular  appearance.  With  the  cancer- 
corpuscles,  and  usually  Avith  granular  matter,  it  makes  the  "cancer 
juice;"  the  peculiar  thick,  creamy  liquid,  tinted  with  yellow,  gray, 
pink,  or  purple,  and  easily  diffusible  in  water.  The  quantity  of  corpus- 
cles in  proportion  to  the  liquid  is  various ;  it  may  be  so  small,  and  the 
corpuscles  themselves  may  be  so  lowly  developed,  that  the  liquid  may 
appear  the  chief  constituent  of  the  cancer. 

{h)  The  same  kind  of  liquid  which,  in  the  cases  just  referred  to,  forms 
the  only  material  suspending  the  corpuscles,  exists,  also,  in  the  solid 
medullary  cancers:  it  is  the  liquid  of  the  "  cancer  juice."  But  in  the 
more  solid  growths  it  appears  to  be  diffused  through  some  solid  tissue, 
or  in  the  interspaces  of  a  kind  of  spongy  texture.  This,  which  may  be 
more  properly  called  a  stroma  of  medullary  cancer,  is  in  its  simplest 
form  a  nearly  pellucid  substance,  having  either  no  trace  of  structure, 
or  only  imbedded  roundish  or  elongated  nuclei ;  but  sometimes  it  ap- 
pears fibrillated. 

(c)  Sometimes  a  framework,  inclosing  and  supporting  cancer-cells, 
appears  to  be  formed  by  elongated  fibro-cells  arranged  in  series  of  com- 
municating lines.  But,  more  commonly,  a  framework  is  constructed  of 
delicate  pellucid  or  nucleated  membrane,  with  filamentous  tissue.  In 
the  last  case  one  obtains  from  a  medullary  cancer,  after  expressing  as 
much  as  possible  of  its  "juice,"  a  kind  of  sponge,  flocculent  and 
shreddy,  constructed  of  membrane  and  filamentous  tissue,  with  blood- 
vessels, and  still-adhering  cancer-particles.  One  thus  sees  that,  even 
in  the  minuter  parts,  the  substance  of  the  growth  is  intersected  with  such 
partitions  as  are  visible  with  the  naked  eye,  separating  its  larger  lobes. 

id)  Lastly,  when  medullary  cancer  is  formed  in  bone  or  periosteum, 
these  tissues  may,  as  I  have  said,  grow  excessively,  and  make  for  it  a 
fibrous  or  osseous  skeleton  (p.  566).     Or,  in  other  cases,  new  fibrous  or 

*  Or,  with  more  advantage,  to  Lebert's  admirable  account  of  the  changes  of  the  cancer- 
cells,  in  his  "  Trait6  pratique,"  p.  23. 


574      MEDULLAKY    CANCER  —  MICROSCOPIC    STRUCTURE. 


osseous  tissue  may  be  formed  in  the  cancer,  and  may  be  as  a  stroma  for 
the  cancer-cells.  Medullary  cancers  thus  composed  are  the  chief  ex- 
amples of  transition-forms  to  the  scirrhous  cancers,  on  the  one  hand ; 
and,  on  the  other,  to  the  osteoid  cancers,  in  which  the  cancer-cells  are 
wholly  or  nearly  superseded  by  an  imperfect  ossific  production. 

Rokitansky  some  time  ago  published  an  essay*  on  the  development 
of  the  stroma  or  skeleton  of  cancers,  an  abstract  of  which,  with  copies 
of  some  of  his  illustrations,  may  find  here  an  appropriate  place.     It 

relates,  almost  entirely,  to 
^'^'  ^^t  that    kind  of    stroma,   in 

medullary  cancers,  which 
is  described  above  {e,  p. 
573). 

In  certain  examples  of 
such  a  stroma  or  skeleton, 
two  interlacing  networks, 
or  meshed  structures,  may 
be  seen  (Figs.  96,  97).  One 
of  these  [b)  consists  of  slen- 
der bands,  beams,  or  tubes 
(Fig.  96,  c)  of  a  hyaline 
substance,  which  contains 
oblong  nuclei,  and  may  be 
in  part  fibrillated  or  trans- 
formed into  filamentous 
tissue.  The  other  and 
younger  structure  (a)  is 
composed  of  larger  opaque 
bands  or  beams,  which  are 
made  up  of  nucleated  cells, 
with  elementary  granules, 
and  variously  perforated. 
These  form  a  network  in- 
terlacing with  that  formed 
by  the  hyaline  structures. 
Moreover,  with  these 
opaque  beams,  formed  of 
the  same  structures,  and 
projecting  from  them,  or 
from  the  hyaline  structures, 
there  are  hollow  flask- 
shaped  or  villous  processes 

*  Ueber  die  Entwickelung  der  Krebsgeriiste,  1852,  from  the  Sitzungsberichte  der  Kais. 
Akademie. 

t  Figs.  96  and  97.  Development  of  cancer-stroma,  described  in  the  text.  Magnified  90 
times.     From  Rokitansky. 


Fig.  97.t 


MEDULLARY     CANCER  —  MICROSCOPIC     STRUCTURE.       575 

or  outgrowths  (Fig.  97).  Many  of  these  pass  through  the  apertures  or 
meshes  in  the  networks,  projecting  through  them  with  free  ends ;  and 
the  apertures  with  which  manj  of  them  are  perforated,  enlarging  by 
absorption,  give  them  the  appearance  of  netted  hollow  bands  or  cords. 
Some  of  these  same  processes,  also,  appear  pellucid,  hyaline,  and  nucle- 
ated at  their  bases  or  pedicles  of  attachment,  or  through  more  or  less 
of  their  length. 

These  several  conditions  of  the  stroma  indicate,  Rokitansky  says, 
that  it  is  constructed  on  that  plan  of  "  dendritic  vegetation,"  of  which 
the  type  and  best  example  is  in  the  villous  cancers.  The  growth  of 
the  stroma  takes  place,  at  first,  in  the  form  of  hollow,  flask-shaped,  bud- 
ding and  branching  processes  or  excrescences,  which  are  composed  of 
hyaline  membrane,  and  filled  with  nucleated  cells  and  granules.  These 
processes  constantly  increase,  throwing  out  fresh  offshoots  of  the  same 
shape  as  themselves  first  had  (comparably  with  the  increase  of  the  exo- 
genous villi  of  the  cystic  chorion  described  at  p.  378).  At  the  same  time 
the  cells,  or  part  of  the  cells,  within  the  processes,  unite  or  fuse  their 
cell-walls,  while  their  nuclei  remain  and  are  elongated.  Thus  the  tex- 
ture of  the  growing  stroma  becomes  hyaline,  nucleated,  or  at  last  fila- 
mentous and  tubular  ;  and,  as  apertures  are  formed  in  it  by  partial 
absorption  of  its  textures,  it  becomes  also  meshed  and  reticulate  or 
sponge-like.  Fresh  dendritic  vegetations  arising,  on  the  same  plan, 
from  the  network  thus  formed,  pass  with  interlacements  through  its 
meshes  ;  and,  by  repetition  of  the  changes  just  described,  increase  the 
stroma  and  the  complexity  of  its  construction. 

The  production  of  cancerous  elements  is  commensurate  with  the 
growth  of  the  stroma,  and  they  fill  all  the  interstices,  as  well  as,  in 
some  cases,  the  tubules  of  the  networks.* 

*  Rokitansky  holds  that  the  same  method  of  construction  is  to  be  traced  in  the  formation 
of  the  layers  of  false  membrane,  which  are  found  with  reticulate  or  areolar  surfaces,  or, 
later,  with  interlacing  laminae  of  fibres,  on  the  pleura  and  other  serous  membranes.  He 
illustrates  it,  also,  by  the  reticulate  deposits  on  the  interior  of  arteries;  and,  lastly,  by  the  ex- 
amples of  cavernous  or  erectile  tumors,  i.  e.,  not  of  such  as  he  admits  to  be  formed  by  dila- 
tation of  bloodvessels,  but  of  such  as  are  entirely  new-formed  structures.  I  have  supposed 
these  (see  p.  504)  to  be  new  growths,  in  which  the  bloodvessels  greatly  enlarging  produce 
the  character  of  an  erectile  tissue.  Rokitansky  says  that  processes  spring  from  the  bands 
and  the  cords  of  the  cavernous  tissue  of  such  tumors,  which  processes  end  with  flask-shaped 
swellings,  and  are  either  opaque,  and  formed  of  nucleated  cells,  or  are  formed  of  nucleated 
hyaline  tissue,  or  of  long  fibro-cells,  or  of  fibro-cellular  tissue.  From  these  likenesses  he 
deduces  for  the  cavernous  tumors  the  same  plan  of  development  as  for  the  stroma  of  cancer. 
He  believes,  moreover,  that  the  blood  which  some  of  them  contain  is  formed  in  them:  say- 
ing that,  in  small,  lately-formed  erectile  tumors,  no  anastomosis  between  their  blood-spaces 
and  the  bloodvessels  in  the  parts  around  them  can  be  found. 

Lastly,  he  says  (and  the  statements  may  be  added  to  what  is  mentioned  at  p.  508),  the 
affinity  of  the  cavernous  blood-tumor  with  cancer  is  more  than  a  formal  one.  They  not 
unfrequently  exist  together  in  the  same  organ,  e.  ff.,  in  the  liver;  and  the  stroma  of  the  can- 
cer may  be  exactly  like  the  mesh  work  of  the  vascular  tumor.  Cavernous  tumors,  also,  may 
be  found  in  large  numbers  at  once  in  the  most  different  organs  and  tissues:  for  example  (as 


576  MEDULLARY     CANCER    OF    THE    TESTICLE. 

The  foregoing  descriptions,  though  illustrated  hy  only  a  few  exam- 
ples, might  suffice,  I  believe,  for  the  medullary  cancers  of  nearly  all 
parts.  Yet  it  may  be  useful,  if,  after  the  example  of  the  other  lectures, 
I  describe  some  of  the  peculiarities  which  this  form  of  cancer  presents 
in  certain  organs, — making  a  selection  on  the  same  grounds  as  in  the 
last  lecture  (p.  533). 

In  the  Testicle,  the  medullary  cancer  is,  usually,  of  the  softer  kind  : 
the  firmer  kind  is  not  uncommon,  but  examples  of  the  scirrhous,  or  any 
other  form  of  cancer,  except  the  medullary,  are  of  exceeding  rarity. 

The  medullary  cancer  commonly  appears  as  a  regular  oval,  or  pyri- 
form  mass,  which  the  toughness  of  the  inclosing  fibrous  coat  of  the  tes- 
ticle permits  to  grow  to  a  great  size  without  protrusion.  As  the  fibrous 
texture  is  distended  by  the  growth,  so  it  commonly  also  increases  in 
thickness.  The  surfaces  of  the  tunica  vaginalis  are  generally  partially 
adherent ;  and  what  remains  of  the  cavity,  usually  at  its  upper  part, 
is  filled  with  serous  or  blood-tinged  fluid.  Part,  or  the  whole,  of  the 
glandular  tissue  of  the  testicle  may,  I  think,  be  always  found  outspread 
on  the  surface  of  the  tumor  :  the  epididymis,  often  the  seat  of  similar 
disease,  is  generally  flattened  and  expanded.  Separate  medullary  can- 
cers may  lie  near ;  especially  in  the  loose  areolar  tissue  of  the  spermatic 
cord :  or  the  growth  may  perforate  the  tunica  albuginea,  and  extend 
exuberantly  about  the  testicle  in  the  sac  of  the  tunica  vaginalis,  or  in 
the  loose  tissue  of  the  scrotum  :  or,  without  communication,  part  of  the 
cancer  may  be  within,  and  part  around,  the  tunica  albuginea.* 

The  general  characters  of  the  cancer-structure  in  the  testicle  are 
usually  conformed  to  the  type  already  described,  yet  these  points  may 
be  considered  worthy  of  note.  (1.)  Sometimes  the  lobes  of  the  can- 
cerous mass  are  severally  so  invested  with  connective  tissue  that  they 
may  have  the  appearance  of  cysts  filled  with  endogenous  cancerous 
growths. t     (2.)  Portions,  or  whole  lobes,  of  the  tumor,  degenerate  and 

in  a  case  related  by  him),  in  the  whole  peritoneum,  the  costal  pleura,  the  subcutaneous  tis- 
sue, one  of  the  psoas  muscles,  the  choroid  plexuses,  and  the  fat  at  the  base  of  the  heart. 

Many  of  the  later  writers  on  the  structure  of  cancer  consider,  that  both  the  cancer-cells 
and  the  peculiar  trabecular  stroma,  in  the  spaces  between  which  the  cancer-cells  are  lodged, 
are  developed  from  the  original  connective  tissue  of  the  part  in  which  the  cancer  is  situated. 
This  development  being  due  to  the  proliferation  of  the  corpuscles  of  the  connective  tissue, 
which,  on  the  one  hand,  may  produce  the  cancer-cells,  on  the  other,  may  develop  in  such 
a  way  as  to  form  the  peculiar,  villous,  papillary,  or  dendritic  vegetations  above  described. 
When  once  formed,  these  trabeculse  may  increase  in  size  through  the  activity  of  the  cells 
contained  in  their  interior.  In  this  manner  a  structure  and  general  plan  of  arrangement 
may  be  produced  not  unlike  that  which  has  already  been  described  in  cylindroma,  p.  416. 

*  Mr.  Prescott  Hewett  showed  me  a  specimen  in  which  a  healthy  testicle  was  surrounded 
by  medullary  cancer.  Examples  of  similar  cancers  in  the  spermatic  cord,  the  testicles  being 
healthy,  are  in  the  College  Museum,  Nos.  2462-3  :  some  affecting  the  undescended  testicles 
are  related  by  Mr.  Arnott  (Med.-Chir.  Trans.,  xxx,  p.  9),  and  by  Dr.  Fayrer  in  Edin.  Month. 
Med.  Jal,  March,  1863. 

t  Mus.  Coll.  Surg.,  No.  2396. 


MEDULLARY    CANCER     OP    THE     BREAST.  577 

withered  into  a  yellow  substance,  like  tuberculous  or  "  scrofulous" 
matter,  are  usually  seen ;  especially  near  the  central  parts  of  the  can- 
cer. (3.)  Large  cavities  full  of  blood  may  exist,  and  add  to  the  diffi- 
culty of  the  diagnosis  from  hsematocele.  (4.)  The  conjunction  of  me- 
dullary cancer  with  cartilage  is  more  frequent  in  the  testicle  than  in 
any  other  part  (see  p.  459).  (5.)  The  disease  very  rarely  affects  both 
testicles,  either  at  once  or  in  succession. 

The  medullary  cancer  of  the  Eye  so  rarely  deviates  from  the  general 
characters  of  the  disease,  and,  since  Mr.  Wardrop's  first  account  of  it, 
has  been  described,  in  all  works  on  Ophthalmic  Surgery,  so  much  more 
fully  than  would  here  be  reasonable,  that  I  shall  advert  to  only  two 
points  which  it  illustrates.  (1.)  It  is  especially  apt  to  present,  either 
in  parts  or  throughout,  the  melanotic  form  ;  a  fact  which  we  can  hardly 
dissociate  from  that  of  its  growth  near  a  seat  of  natural  black  pigment, 
and  which  illustrates  the  tendency,  even  of  cancers,  to  conform  them- 
selves, in  some  degree,  to  the  structures  of  adjacent  healthy  parts.  (2.) 
It  shows  a  remarkable  disregard  of  tissue  in  its  election  (if  it  may  be  so 
called)  of  a  seat  of  growth.  I  fully  agree  with  M.  Lebert  in  his  denial 
of  the  opinion  that  either  the  retina,  or  any  other  tissue  of  the  eyeball, 
is  in  all  or  even  in  a  large  majority  of  cases  the  place  of  origin  of  the 
cancer.  Rather,  we  have,  here,  a  striking  instance  of  what  may  be 
called  the  allocation  of  cancers  :  of  their  growth  being  determined  to 
certain  places  rather  than  to  certain  tissues.  Any  of  the  tissues  within 
or  about  the  globe  of  the  eye,  or  any  two  or  more  of  them  at  a  time, 
may  be  the  primary  seat  of  the  cancer  ;  and,  probably,  each  of  them  is 
more  liable  to  be  so  than  any  similar  tissue  elsewhere  is:  the  locality, 
therefore,  which  they  all  occupy,  may  be  assumed  as  that  to  which  the 
cancerous  growth  is  directed,  rather  than  any  of  the  tissues  themselves. 
And  so  it  appears  to  be,  when,  after  extirpation,  the  cancer  returns,  as 
if  with  preference,  in  the  same  locality,  although  the  whole  of  the  first 
growth,  and  of  the  tissues  which  it  occupied,  are  removed. 

The  Breast  is  among  the  parts  which  are  most  rarely  the  seats  of 
medullary  cancer.  I  cannot  tell  exactly  the  proportion  which  the  cases 
of  medullary  bear  to  those  of  scirrhous  cancer ;  but  I  think  it  is  not 
greater  than  five  to  ninety-five  in  this  country  ;  an  infrequency  which 
seems  the  more  remarkable  by  its  contrast  with  the  occurrence  of  the 
disease  abroad.  In  France,  according  to  M.  Lebert,*  about  one-fifth 
of  the  cancers  of  the  breast  are  "soft  and  encephaloid."  In  America, 
Dr.  J.  B.  S.  Jackson  has  assured  me  that  the  proportion  is  not  less 
than  one-fifth  ;  and  I  gather,  from  the  records  of  German  writers,  that 
it  is  with  them  about  the  same. 

I  have  never  seen,  in  the  recent  state,  a  medullary  cancer  of  the 

*  Des  Maladies  Cancereuses,  p.  326. 


578  MEDULLARY    CANCER     OF    THE    BREAST. 

breast  which  had  a  brain-like  or  any  other  usual  appearance:*  but  I 
have  observed  four  cases  of  what  must  be  regarded  as  medullary  cancer, 
though  widely  deviating  from  the  usual  characters,  and  not  resembled 
by  any  of  the  same  kind  except  some  of  those  occurring  in  the  brain. 
They  may  be  worth  description,  because  they  are  with  difficulty  dis- 
tinguished from  hard  cancers,  on  the  one  hand,  and  from  mammary 
glandular  or  cystic  tumors,  on  the  other.  If  a  general  description  may 
be  drawn  from  these  few  cases,  it  may  be  to  the  following  effect. 

The  tumors  are  separable  masses,  closely  connected  with  the  sur- 
rounding mammary  gland  or  fat,  but  not  incorporated  with  them,  and 
having,  in  some  instances,  distinct  thin  capsules, — a  character  at  once 
distinguishing  them  from  all  the  scirrhous  cancers  of  the  breast  that  I 
have  yet  seen.  They  are,  generally,  seated  on  or  near  the  surface  of 
the  gland,  "floating,"  as  mammary  glandular  tumors  often  do.  The 
skin  over  them  is  upraised,  thin,  and  tense  ;  not  depressed,  or  morbidly 
adherent,  or  itself  cancerous  ;  but  when  ulceration  is  at  hand,  becoming 
livid,  then  ulcerating  sparingly,  and  then  everted  with  the  protruding 
and  outgrowing  tumor.  The  tumors  are  oval,  flattened,  rounded,  or 
nodular ;  firm,  sometimes  very  firm,  but  not  hard  or  very  heavy  like 
scirrhous  cancers,  and  at  or  about  their  centres  they  feel  like  cysts 
tensely  filled  with  fluid.  They  may  grow  quickly,  and  to  much  larger 
size  than  scirrhous  cancers;  are  not  remarkably  painful ;  and  appear 
prone  to  be  associated  with  the  formation  of  large  serous  cysts.  Their 
general  history  is  that  of  ordinary  medullary  cancers. 

With  these  characters  alone,  the  diagnosis  of  such  medullary  cancers 
of  the  breast  is  very  difficult ;  all  these  equally  belong  to  mammary 
glandular  tumors  or  proliferous  mammary  cysts.  But  the  same  disease 
may  exist  in  the  axillary  lymphatic  glands,  forming  quickly-growing 
masses,  apt  to  be  much  larger  than  those  in  scirrhous  cancer.  And,  if 
ulceration  ensue  in  the  tumor,  it  becomes  exuberant,  with  lobed  and 
coarsely-granulated  firm  growths,  discharging  offensive  ichor,  and  some- 
times profusely  bleeding. 

When  such  tumors  are  removed,  they  are  found,  as  already  stated, 
separable  from  the  mammary  gland ;  it  is  pressed  away  by  them,  but 
is  itself  healthy.  The  section  of  the  tumor  is  minutely  lobed,  with 
lobes  or  "granulations"  closely  grouped,  like  those  of  a  mammary 
glandular  tumor.  Their  texture  is  close,  more  or  less  firm,  easily 
crushed,  shining  on  the  cut  surface.  In  color,  they  are  grayish,  varied 
with  dots  and  irregular  lines  of  yellow  (which  do  not  follow  the  course 
of  the  gland-ducts),  or,  in  parts,  suffused  with  livid  or  deeper  purple 
tints.  Parts  of  them,  or  even  whole  lobes,  may  be  soft,  shreddy,  pale 
yellow,  like  tuberculous  infiltration ;  and  these  seem  to  be  portions  that 

*  I  do  not  so  consider  two  specimens  in  the  Museum  of  St.  Bartholomew's,  Series  xxxv, 
28,  29,  removed  from  the  front  of  the  chest  after  amiautation  of  the  breasts  on  account  of 
extreme  hypertrophy. 


MEDULLARY    CANCER    OF    THE    SUBCUTANEOUS    TISSUE.       579 

are  degenerate  and  withered,  like  the  tuberculoid  materials  in  other 
medullary  cancers.  They  yield,  not  a  creamy  fluid,  but  a  turbid  gray- 
ish, or  viscid  yellowish  one.  In  some  instances  large  cysts  lie  in  or 
upon  them,  filled  with  serous,  or  blood-stained,  or  darker  fluid. 

In  microscopic  examination  traces  of  a  glandular  acinous  plan  may 
be  again  observed  :  the  corpuscles  of  the  tumor  being,  at  least  in  parts, 
grouped  in  round  or  oval  forms,  though  the  groups  are  not  inclosed  in 
membrane.  The  corpuscles  may  be  well-formed  cancer-cells  and  nuclei 
imbedded  in  molecular  substance.  But  I  have  also  found  in  them,  with 
these  or  alone,  abundant  nuclei  (some  free  and  some  in  cells),  such  as 
are  described  at  page  570,  Fig.  92.  It  was,  chiefly,  such  nuclei  as 
these,  which,  being  clustered,  gave  the  minute  appearance  of  glandular 
construction:  and  in  some  parts,  these  alone,  clustered  and  close 
packed,  seemed  to  make  up  nearly  the  whole  substance  of  the  tumor. 

In  the  Subcutaneous  Tissue,  or  deeper  areolar  layer  of  the  skin, 
the  medullary  cancers,  while  generally  conformed  to  the  type,  exhibit 
these  peculiarities : 

(1)  They  are  apt  to  assume  the  melanotic  state ;  a  fact  allied  to  that 
already  mentioned  of  the  cancers  of  the  eyeball. 

(2)  While,  in  nearly  all  other  external  parts,  the  medullary  cancers 
appear  as  single  growths,  they  are  here  very  often  multiple.  Such 
numerous  cancers  may  grow  after  one  affecting  some  distant  organ ;  or 
may  be  first  formed  below  the  cutis.  In  the  latter  case,  many  may 
appear  coincidently ;  or,  when  in  succession,  none  seem  to  be  conse- 
quences of  the  growth  of  their  predecessors ;  they  all  have  the  charac- 
ters of  primary  cancers,  of  "  cancers  d'emblde."  In  some  cases  all  the 
tumors  appear  in  a  single  region  of  the  body.  In  an  old  man,  lately 
under  Mr.  Lawrence's  care,  two  medullary  cancers  were  removed  from 
the  scalp,  and  four  remained  in  it.  In  a  case,  which  I  shall  presently 
detail,  a  large  number  were  seated  on  one  arm  and  shoulder,  but  scarcely 
any  appeared  elsewhere.  In  some  cases,  on  the  other  hand,  they  ap- 
pear at  about  the  same  time  in  many  and  distant  parts ;  and  in  some, 
though  limited  at  first  to  a  single  region,  they  grow  successively  in 
other  parts  more  and  more  widely  distant.  Such  was  the  event  in  a 
remarkable  case  by  Dr.  Walshe.* 

In  this  aptness  to  be  the  seat  of  many  medullary  tumors,  the  subcu- 
taneous tissue  agrees  most  nearly  with  the  serous  membranes  and  the 
liver  and  other  glands.  The  separable  tumors  are  generally  isolable, 
oval,  discoid,  or  lens-shaped :  very  rarely,  I  believe,  they  are  peduncu- 
lated :  they  do  not  commonly  grow  to  a  great  size,  or  tend  to  ulcera- 
tion or  protrusion,  unless  after  injury.     But  there  seems  no  limit  to 

*  Medical  Times  and  Gazette,  Aug.  21  and  28,  1S52.  In  his  treatise  on  Cancer,  Dr. 
Walshe  gives  a  fnll  analysis  of  all  the  cases  previously  published.  See  also  the  singular 
case  recorded  by  Mr.  Ancell  (Med.  Chir.  Trans.,  xxv,  p.  227). 


580        MEDULLARY    CANCER    OF    THE    LYMPHATIC    GLANDS. 

their  number ;  it  is  as  if  the  force  of  the  disease  which,  in  other  in- 
stances, is  spent  in  a  single  enormous  growth,  were  here  distributed 
among  many. 

(3)  It  is  chiefly  among  these  examples  of  multiple  medullary  cancers 
that  the  occasional  disappearance  of  a  cancer,  as  if  by  absorption,  may 
be  observed.  The  old  man  referred  to,  as  under  the  care  of  Mr.  Law- 
rence, was  admitted  because  one  of  the  tumors  in  his  scalp  was  largely 
and  foully  ulcerated.  The  removal  of  it  was  deferred,  on  account  of 
the  other  tumors,  and  especially  on  account  of  one  behind  the  ear ;  but 
in  the  course  of  about  a  month  this  almost  wholly  disappeared ;  the 
largest  of  those  remaining  was  now  removed ;  and  during  the  healing 
of  the  wound  the  rest  nearly  disappeared,  becoming  gradually  smaller 
and  firmer.  So,  in  the  case  of  multiple  tumors  of  the  arm,  before  the 
patient  died,  the  whole  of  the  smaller  tumors  were  completely  removed 
during  the  sloughing  and  suppuration  of  the  larger. 

The  Lymphatic  Glands,  so  rarely  the  seat  of  primary  scirrhous 
cancer,  are  often  primarily  affected  with  medullary  cancer.  They  are, 
indeed,  less  frequently  so  affected  than  they  seem  to  be ;  for,  in  some 
instances,  when  the  disease  seems  primary  in  them,  it  is  only  because 
of  its  predominance  over  that  in  the  organ  with  which  they  are  con- 
nected. But,  in  more  instances  than  these  the  glands  are  first,  and  for 
a  time,  exclusively  affected.  The  most  frequent  seats  of  such  primary 
disease  are  the  cervical,  inguinal,  lumbar,  axillary,  and  mediastinal 
glands  :  in  a  few  very  rare  instances  nearly  the  whole  lymphatic  system 
has  quickly  become  cancerous. 

The  primary  cancer  of  the  lymphatic  glands  usually  affects,  from  the 
first,  more  than  one  gland  ;  often,  it  extends  through  a  whole  group, 
and  so  many  tumors  form  in  a  cluster,  that  one  may  doubt  whether  all 
of  them  are  in  glands.  They  may  present  any  of  the  various  forms  of 
medullary  cancer ;  and  these  peculiarities  may  be  noticed  in  their 
course  :  (1)  They  are  rarely  well  marked  in  the  first  instance ;  they 
appear  like  merely  enlarged  glands ;  their  constant  and  accelerating 
increase  may  alone  suggest  the  suspicion  of  the  nature  of  the  disease. 
(2)  Cyst-formation  is  frequent  in  connection  with  them.  Especially,  I 
think,  in  the  neck,  one  may  find  serous  cysts,  in  elderly  persons,  rest- 
ing on  clusters  of  cancerous  glands,  and  the  cysts  may  be  often  eva- 
cuated, and  will  fill  again,  while  the  main  disease  makes  insidious 
progress  deep  in  the  neck.  (3)  Partial  suppurations  may  occur  in  the 
cancerous  glands,  rendering  the  diagnosis  for  a  time  still  more  difficult. 
(4)  It  is  especially  among  the  cases  of  cancerous  lymphatics  that  we 
may  find  those  occurrences  of  deep  connection,  and  of  inclosing  of  large 
nerves  and  bloodvessels,  to  which  I  have  referred  (p.  563).  (5)  Can- 
cerous lymphatic  glands  often  give  a  fallacious  support  to  the  belief 
that  innocent  tumors  are  apt  to  become  cancerous ;  for  the  glands  some- 
times enlarge  before  the  cancerous  disease  is  established  in  them ;  and 


MEDULLARY    CANCER  —  PATHOLOGY.  581 

since,  in  their  simple  enlargement,  they  are  like  simple  tumors,  there 
is  an  appearance  of  transmutation,  when  in  such  a  state  they  become 
the  seats  of  cancer. 

In  the  Rectum,  and  in  other  parts  of  the  digestive  canal,  I  have 
already  said  that  growths  of  medullary  cancer  may  coexist  with  scir- 
rhous cancer.  Whether  in  this  combination  or  alone,  the  former  dis- 
ease may  appear  in  at  least  three  distinguishable  forms.  (1)  It  consists 
sometimes  in  diffuse  infiltration  of  creamy,  white,  or  grayish  cancerous 
substance  in  the  submucous  tissue,  the  mucous  membrane  being,  for  a 
time,  healthy,  but  raised  into  the  canal  with  low  unequal  elevations. 
(2)  Much  more  commonly,  larger  and  more  tuberous  circumscribed 
masses  grow  in  the  submucous  tissue,  projecting  and  soon  involving  the 
mucous  membrane,  then  exuberant  through  ulcerated  apertures  in  it 
and  often  bleeding,  (3)  With  nearly  equal  frequency  the  disease  has 
its  primary  seat  in  the  mucous  membrane.  Here  it  forms  broad,  cir- 
cular, or  annular  growths,  of  a  soft,  spongy,  and  shreddy  substance. 
They  are  but  little  raised  above  the  level  of  the  mucous  membrane,  unless 
it  be  at  their  margins,  which  are  usually  elevated  and  overhanging,  and 
when  ulcerated,  sinuous  and  everted.  They  are  very  vascular,  justi- 
fying Rokitansky's  expression,  that  the  bloodvessels  of  the  affected  part 
of  the  membrane  have  assumed  the  characters  of  those  of  an  erectile 
tissue.  They  might  produce  little  stricture  of  the  canal,  if  it  were  not 
that  they  are,  I  think  frequently,  associated  with  thickening  and  con- 
traction of  the  tissue  external  to  them. 

It  hardly  needs  to  be  added  that  in  whichever  part  of  the  intestine 
the  disease  commences,  it  extends  to  the  rest,  and  from  them  to  the 
surrounding  tissues ;  exemplifying  here  as  everywhere  the  coincident 
processes  of  destruction  and  of  more  abundant  formation.* 


LECTURE    XXXI. 

MEDITLLAKY    C  A  N  C  E  K. 
PART    II. — PATHOLOGY. 

The  general  history  of  medullary  cancers  presents  the  best  marked 
type  of  malignant  growths.  Among  all  tumors,  they  appear,  in  a  gene- 
ral view,  the  most  independent  of  seat  and  of  locality  ;  the  most  rapid 

*  When  I  have  omitted  all  description  of  the  medullary  cancers  of  the  uterus,  lungs, 
brain,  and  many  other  organs  in  which  they  frequently  occur,  it  will  not,  I  hope,  be  forgotten, 
that  my  purpose  is  only  to  illustrate  the  general  pathology  of  the  disease  by  the  best  ex- 
amples which  I  have  been  able  to  study.  To  have  entered  further  on  the  special  pathology 
of  cancer  in  each  organ  would  have  been  beyond  my  purpose,  and  quite  superfluous  while 
-.he  great  works  of  Walshe  and  Lebert  can  be  consulted, 


582 


MEDULLARY    CANCER. 


in  growth  ;  the  most  reckless  in  the  invasion  of  diverse  tissues ;  the 
most  abundant  in  multiplication :  they  have  the  most  evident  constitu- 
tional diathesis ;  they  are  the  most  speedily  fatal.  All  these  facts  will 
be  illustrated  by  comparison  of  the  following  sketch  with  the  correspond- 
ing histories  of  the  other  forms  of  cancer. 

(a)  Among  the  conditions  favoring  the  production  of  medullary  can- 
cer, the  peculiarities  of  the  female  sex,  though  not  without  influence, 
appear  far  less  powerful  than  they  appear  in  the  history  of  scirrhous 
cancers.  The  peculiar  liability  of  the  uterus  so  much  surpasses  that 
of  any  of  the  male  organs  of  generation,  that  women  are  certainly,  on  the 
whole,  more  liable  than  men  are  to  this  form  of  cancer.  But  when 
the  medullary  cancers  of  the  generative  organs  of  both  sexes  are  left 
out,  the  majority  of  the  remaining  cases  are  found  among  males. 

(h)  The  medullary  cancer  is  prone  to  occur  at  an  earlier  age  than  any 
other  form  ;  it  is,  indeed,  almost  the  only  cancerous  disease  that  we 
meet  with  before  puberty.  The  three  localities  in  which,  according  to 
M.  Lebert,*  cancer  occurs  at  thf3  lowest  mean  age  are  (in  the  order  of 
their  liability),  the  eye,  the  testicle,  and  the  osseous  system.  To  these, 
while  confirming  his  observation,  I  would  add,  the  intermuscular  spaces, 
and  other  soft  parts  of  the  trunk  and  limbs.  The  mean  age  of  the 
occurrence  of  cancer  in  these  parts  is  under  40 ;  in  all  other  parts  it  is 
above  40,  and  in  most  of  them  above  50.  Now,  the  four  localities  named 
above  are  those  in  which  the  medullary  and  melanotic  cancers  almost 
alone  occur  as  primary  affections. 

From  a  tablef  of  154  primary  medullary  cancers  of  the  bones,  soft 
parts  of  the  trunk  and  limbs,  the  eye  and  orbit,  the  testicle,  breast,  and 
various  other  external  parts,  T  find  that  the  ages  at  which  they  occurred 
were  as  follows  :  I 


Breast. 

1 

Soft 

parts  of 

limbs 

and 

trunk. 

Lym- 
phatic 
glands 
and 
other 
parts. 

Bones. 

Eye  and 
orbit. 

Testicle. 

Total. 

Before  10  years  of  age,    . 
Between  10  and  20,     .     .     . 

"        20    "    30,     .     .     . 
30    "    40,     .     .     . 

"         40    "    50,     .     .     . 

"         50    "    60,     .     .     . 
Above      60 

ft 

2 
6 
3 

3 

6 

■    2 

1 

3 

2 
2 
3 

4 

12 

11 

6 

11 

4 

6 

15 
1 
4 

2 
1 
5 
3 

4 
2 
12 
17 
8 
3 

25 
21 
33 
32 
30 
20 
10 

7 

23 

10 

54 

31 

46 

171 

The  striking  contrast  between  this  table  and  that  of  the  158  cases       aj 
of  scirrhous  cancer  (p.  542)  needs  little  comment.     Of  the  scirrhous      | 

*  Traite  Pratique,  p.  140.   See  also  one  of  the  tables  in  Med.-Chir.  Trans.,  vol.  xlv,  p.  393. 

f  The  table  is  constructed  from  nearly  equal  numbers  of  M.  Lebert's  cases  and  my  own; 
and  it  may  be  made  worthy  of  remark,  that  in  the  case  of  every  part  the  average  age  is 
higher  in  his  cases  than  in  mine. 


0  to  10 

years, 

10    "    20 

^i 

20    "    30 

li 

30   »    40 

" 

40    «    50 

u 

50    "    60 

u 

Above  60 

« 

HEREDITARY    INFLUENCE.  583 

cancers,  not  one  occurred  before  the  age  of  20  ;  of  the  medullary  can- 
cers, more  than  a  fourth  began  before  that  age  :  of  the  former,  nearly 
half  commenced  their  growth  between  40  and  50  years  of  age ;  of  the 
latter,  little  more  than  a  sixth  :  of  the  former,  nearly  three-fourths 
commenced  after  40 ;  of  the  latter,  little  more  than  one-third  did  so. 

The  following  table,  also,  may  be  compared  with  that  at  p.  543.  It 
shows,  by  similar  calculations,  the  relative  frequencies  of  medullary  can- 
cers in  external  parts,  in  proportion  to  the  number  of  persons  living 
at  each  of  the  successive  decennial  periods  of  life.  The  greatest  fre- 
quency is  between  40  and  50,  and  reckoning  this  as  100,  the  following 
numbers  may  represent  the  frequencies  of  the  beginning  of  medullary 
cancers  at  other  decennial  periods  : 

31 

38 
59 
79 
100 
99 
44 

The  chief  points  which  this  table  may  illustrate  are  (1),  that  the 
maximum  of  frequency,  in  proportion  to  the  number  of  persons  living 
at  the  several  ages,  occurs  between  40  and  50,  as  well  for  the  medul- 
lary as  for  the  scirrhous  cancers  of  external  parts ;  but  (2)  that  there 
is  a  gradual  ascent  to  this  maximum  from  the  earliest  period  of  life,  and 
then  a  more  gradual  descent  from  it. 

I  believe,  however,  that  if  we  could  reckon  the  frequencies  of  medul- 
lary cancers  of  internal  organs,  we  should  find  no  such  diminution  after 
the  age  of  50.  Rather,  it  would  appear  that  (in  consequence,  chiefly, 
of  the  frequency  of  cancer  of  the  stomach,  rectum,  and  bladder  in  ad- 
vanced life)  the  frequency  of  medullary  cancers,  in  proportion  .to  the 
number  of  persons  living,  continues  to  increase  up  to  the  latest  age. 
There  are,  I  believe,  no  tables  in  which  the  medullary  are  separated 
from  other  cancers  of  internal  organs  ;  but  from  those  of  the  cancers  of 
the  uterus  and  stomach  given  by  Lebert,  and  of  the  lungs  by  Walshe 
(of  which,  doubtless,  the  majority  were  medullary  cancers),  the  pro- 
portionate frequencies  at  successive  periods  appear  to  be  as  follows. 
(For  comparison's  sake,  the  proportion  between  40  and  50  years  is  still 
counted  as  100.) 

0  to  10  years, 0 

10  "  20     "  (cancers  of  the  lungs  alone),     ....  3 

20  "  30  « 15.7 

30  "  40  " 51 

40  "   50  "            . 100 

50  «  60  " 204 

60  "   70  " 236 

70  "   SO  "  (cancers  of  the  stomach  almost  alone),      .          .  250 

There  are  no  data  from  which  we  could  exactly  reckon  the  relative 


584  MEDULLARY    CANCER. 

frequencies  of  medullary  cancer  in  each  part  of  the  body,  but  there  can, 
I  think,  be  little  doubt  that  it  is  a  disease  which,  on  the  whole,  becomes 
constantly  more  frequent,  in  proportion  to  the  number  of  persons  living 
at  each  successive  period  of  life,  from  the  very  earliest  to  the  latest  age. 

(c)  The  influence  of  hereditary  tendency  is,  probably,  about  the  same 
in  medullary  as  in  scirrhous  cancer.  Among  thirty-two  patients,  five 
were  aware  of  cancer  having  occurred  in  other  members  of  their  fami- 
lies, and  of  these  five,  four  reported  that  two  members  of  their  re- 
spective families  had  died  cancerous. 

{d)  Among  fifty-seven  patients  with  medullary  cancer  of  external 
parts,  seventeen  gave  a  clear  history  of  previous  injury  or  disease  of 
the  part  affected ;  in  seven  the  history  was  doubtful. 

Certainly  it  would  be  impossible  to  prove,  in  many  of  these  cases, 
that  the  cancer  was,  in  any  sense,  consequent  on  the  injury  after  which 
it  formed ;  and  yet,  while  we  find  that  a  third  of  the  patients  with  me- 
dullary cancers  ascribe  them  to  injury  or  previous  disease,  while  less 
than  a  fifth  of  those  with  simple  tumors,  or  with  hard  cancers,  refer 
them  to  such  cause  (p.  545),  we  cannot  fairly  doubt  that  these  local 
accidents  have  influence  in  determining  the  place  and  time  in  which  the 
medullary  cancerous  disease  shall  manifest  itself. 

The  influence  of  injury  is  very  clearly  shown  in  certain  cases,  in 
which  there  is  no  appreciable  interval  between  its  immediate  ordinary 
consequences  and  the  growth  of  a  medullary  cancer  in  the  injured  part. 
For  example,  a  healthy  boy  was  accidentally  wounded  in  the  eye.  It 
had  been  perfectly  sound  to  this  time  ;  but,  within  a  few  days  after  the 
injury,  a  medullary  tumor  grew  from  the  eyeball.  It  was  removed 
three  weeks  later ;  but  it  quickly  recurred  and  destroyed  life. 

A  boy  fell  and  struck  his  knee.  It  had  been  perfectly  healthy ;  but 
the  inflammatory  swelling  (as  it  was  supposed)  that  followed  the  fall 
did  not  subside ;  rather,  it  constantly  increased ;  and  in  a  few  weeks  it 
became  probable  that  a  large  medullary  tumor  was  grooving  around  the 
lower  end  of  the  femur.     Amputation  proved  this  to  be  the  case. 

Again,  a  sturdy  man,  at  his  work,  slipped  and  strained,  or  perhaps 
broke,  his  fibula.  Three  days  afterwards  he  had  increased  pain  in  the 
injured  part,  and  at  the  end  of  the  week  swelling,  which,  though  care- 
fully treated,  constantly  increased.  Eight  weeks  after  the  injury  the 
swelling  was  found  to  be  a  large  medullary  growth  around  and  within 
the  shaft  of  the  fibula;   and  the  limb  was  amputated. 

We  must,  I  suppose,  assume  the  previous  existence  of  a  cancerous 
diathesis  in  the  persons  in  whom  these  rare  consequences  of  accidental 
violence  ensued  ;  nevertheless,  their  cases  prove,  as  I  have  said,  the 
influence  of  local  injury  in  determining  the  time  and  place  in  which  the 
cancer  will  be  manifested;  and  they  may  make  us  believe  that,  in  many 
cases,  in  which  a  clear  interval  elapses  between  the  injury  and  the  ap- 
pearance of  the  cancer,  the  effect  of  the  violence,  though  less  immedi- 
ate, is  certain. 


INFLUENCE     OP    GENERAL    HEALTH.  585 

(e)  Although  I  know  of  no  numerical  evidence  to  support  it,  yet  I 
think  the  general  impression  must  be  true  that  medullary  cancer  is 
peculiarly  liable  to  occur  in  those  who  have  many  of  the  features  of  the 
fair  strumous  constitution  :  in  persons  of  fine  complexion,  light  hair  and 
eyes,  pale  blood,  quick  pulse,  and  of  generally  delicate  or  feeble  health. 
Scirrhous  cancer  appears  most  frequent  in  those  who  have  the  opposite 
characters  of  temperament.  A  difference  also  exists  in  relation  to  the 
general  health  of  those  in  whom  the  two  forms  of  the  disease  are  seve- 
rally observed.  I  mentioned  (p.  545,  note)  that  95  per  cent,  of  the 
subjects  of  hard  cancer  appear  to  have  good  gene'ral  health  at  and  soon 
after  its  first  appearance :  the  proportion  of  those  in  the  like  condition 
with  medullary  cancer  is  about  89  per  cent.  ;  the  remainder  have  pre- 
sented from  the  very  beginning  a  loss  of  weight  and  of  muscular  power, 
accelerated  action  of  the  heart,  quick  breathing,  paleness,  and  general 
defect  of  health. 

In  the  growth  of  medullary  cancer  we  may  chiefly  observe  these 
three  things, — (1)  their  multiplicity  in  certain  cases ;  (2)  their  gene- 
rally rapid  rate  of  increase ;  (3)  the  occasional  complete  suspension  of 
growth. 

I  have  referred  to  their  multiplicity  in  the  subcutaneous  tissue,  but 
again  notice  it,  to  mention  the  observation  of  Rokitansky,*  that  medul- 
lary cancers  are  sometimes  developed  in  great  number  in  the  course 
and  among  the  phenomena  of  a  very  acute  typhoid  fever. 

I  do  not  know  what  their  greatest  rate  of  increase  may  be  ;  but  it  has 
in  several  cases  exceeded  a  pound  per  month,  and,  except  in  the  in- 
stances of  some  of  the  cartilaginous  tumors  (p.  443),  it  is,  I  believe, 
unequalled  by  any  other  morbid  growth.  In  general,  the  more  rapid 
the  growth  the  less  is  the  firmness,  and  the  less  perfect  the  development 
of  nuclei  and  cells,  in  the  medullary  tumor.  Their  rapid  increase 
commonly  indicates,  not  a  special  capacity  of  growth  or  multiplication 
of  cells  in  the  tumor  already  formed,  but  an  intense  diathesis,  an  ample 
provision  of  appropriate  materials  in  the  blood.  The  growth  is  by 
simple  increase :  the  materials  once  formed  do  not  normally  change 
their  characters  ;  there  are  no  stages  of  crudity  or  maturity ;  the  dis- 
ease is,  in  its  usual  and  normal  course,  from  first  to  last  the  same. 

But  while  these  things  justify  the  expression  that  the  medullary  is, 
on  the  whole,  the  most  acute  form  of  cancer,  yet  there  is,  I  believe, 
none  in  which  arrest  or  complete  suspension  of  progress  is  so  apt  to 
occur.  These  cases  have  occurred  within  my  own  observation.  A 
man,  38  years  old,  had  a  slight  enlargement  of  one  testicle  for  fifteen 
years,  and  its  rate  of  increase  was  often  inappreciable.  At  the  end  of 
this  time  rapid  growth  ensued.  On  removal,  well-marked  medullary 
and  melanotic  cancer  was  found,  and  was  the  only  apparent  source  of 

*  Pathologische  Anatomie,  i,  373. 
38 


586  MEDULLARY    CANCER. 

the  enlargement.  He  died  soon  after  the  operation  with  recurrence  of 
the  disease. 

A  man,  42  years  old,  had  a  large  increasing  medullary  tumor  of  the 
ilium.  He  had  also  a  tumor  in  the  upper  arm,  which  had  grown  slowly 
for  seven  years,  and  had  been  stationary  for  three  years.  When  he 
died,  the  tumor  in  the  arm  had  as  well-marked  characters  of  medullary 
cancer  as  that  of  the  ilium,  or  of  any  other  of  the  several  parts  in  which 
similar  disease  was  found.* 

A  man,  35  years  old,  had  numerous  medullary  tumors  in  his  right 
upper  arm,  shoulder,  and  axilla,  all  of  which  had  commenced  their 
growth  within  three  months,  and  were  very  quickly  increasing.  One, 
which  appeared  to  be  in  every  other  respect  of  the  same  kind,  had 
been  stationary  for  twelve  years  in  the  groin,  and  another  nearly  as 
long  in  the  neck. 

Sir  Astley  Cooper  removed  a  gentleman's  testicle  for  what  was  be- 
lieved to  be  medullary  cancer.  He  remained  well  for  twelve  years, 
and  then  died  with  certain  medullary  cancer  in  the  pelvis. 

Dr.  Baly  had  a  patient  who  had  observed  for  several  years  a  tumor 
connected  with  two  of  his  ribs.  It  had  scarcely  enlarged,  till  shortly 
before  his  death ;  then  it  quickly  increased,  and,  at  the  same  time,  nu- 
merous medullary  cancers  appeared  about  it  and  in  more  distant  parts. f 

Cases  such  as  these  occur,  so  far  as  I  know,  in  no  cancers  but  those 
of  the  medullary  and  melanotic  kinds.  They  seem  to  be  quite  inex- 
plicable ;  and  as  yet  no  facts  have  been  observed  which  would  show  a 
peculiarity  of  structure  in  the  arrested  cancers  corresponding  with  the 
strangeness  of  their  life. 

As  the  medullary  cancers  grow,  the  parts  about  them  generally  yield, 
and  some  among  them  grow  at  once  in  strength  and  in  extent,  and  for 
a  time  retard  both  the  increase  and  the  protrusion  of  the  tumor.  Be- 
cause the  skin  over  a  medullary  cancer  is  not  often  infiltrated  (as  that 
over  a  hard  cancer  usually  is),  we  do  not  often  see  the  kinds  of  ulcer 
described  in  the  last  lecture  (p.  547).  Neither  is  there,  in  medullary 
cancers  generally,  any  remarkable  proneness  to  ulceration.  The  usual 
course  is,  that,  as  the  tumor  grows,  the  skin  and  other  parts  over  it 
become  thinner  and  more  tense ;  then,  as  the  growth  of  the  tumor  is 
more  rapid  than  theirs,  they  inflame  and  ulcerate,  and  a  hole  is  formed 
over  the  most  prominent  part  of  the  tumor.  There  is  nothing  specific 
or  characteristic  in  this  ulceration  ;  it  is  only  such  as  may  ensue  over 
any  quickly-growing  tumor ;  but  the  continued  rapid  increase  of  the 
cancer  makes  it  protrude  and  grow  exuberantly ;  it  throws  out  fungus, 
as  the  expression  is.     The  exuberant  growth,  exposed  to  the  injuries 

*  Museum  of  Si.  Bartholomew's,  Series  i,  Nos.  235  to  240.  Case  related  by  Mr.  Stanley 
in  Med.-Chir.  Trans.,  xxviii,  p.  317. 

f  The  tumor  on  the  ribs  is  in  the  Museum  of  St.  Bartholomew's.  It  appears  an  ordinary 
medullary  cancer,  with  a  hard  bony  skeleton. 


MODE    OF    GROWTH.  587 

of  the  external  world,  inflames,  and  hence  is  prone  to  softening,  bleed- 
ing, ulcerating,  and  sloughing.*  These  may  keep  down  its  mass  ;  yet 
it  may  grow  to  a  vast  size,  having  only  its  surface  ulcerated ;  lower 
down,  it  usually  adheres  to  the  borders  of  the  apertures  in  the  skin,  and 
overhangs  and  everts  them.  This  is  usually  the  case  with  the  huge 
outgrowths  of  medullary  cancer  that  have  protruded  from  the  eyeball, 
after  penetrating  through  ulcers  of  the  overstretched  cornea  or  sclerotica. 
And  similar  exuberant  growths  are  often  seen  when  medullary  cancers 
have  penetrated  the  walls  of  various  cavities  or  canals :  thus,  e.  g.,  they 
grow  along  the  canals  of  veins  when  they  have  entered  them  by,  it  may 
be,  a  single  small  orifice. 

In  the  cases  of  diffuse  infiltration  of  an  exposed  superficial  tissue 
{e.  g.^  of  the  mucous  membrane  of  the  stomach  or  rectum),  the  cancer 
usually  ulcerates  widely  with  the  tissue  it  affects,  and  herein  imitates 
more  nearly  the  characters  of  the  ulceration  in  scirrhous  and  epithelial 
cancers. 

Through  the  constantly  deepening  cachexia,  with  which  the  increase 
in  the  medullary  cancers  is  usually  commensurate,  and  which  is  aug- 
mented by  the  various  influences  of  the  local  disease,  the  usual  course 
of  the  medullary  cancer  is  uniformly  towards  death ;  and  rapidly 
thither,  even  when  the  growth  does  not  involve  parts  necessary  to  life. 
And  yet,  as  Rokitansky  has  observed, f  there  is  no  form  of  cancer  in 
which  spontaneous  natural  processes  of  healing  so  often  occur.  Doubt- 
less nearly  all  the  reputed  cases  of  the  cure  of  cancer  have  been  errone- 
ously so  regarded ;  yet  instances  may  be  easily  gathered  of  at  least 
temporary  cure ;  and  these  are  important  in  relation  to  the  general 
pathology  of  cancer,  since  they  afford  the  best  examples  of  the  effects 
of  its  degenerations  and  diseases,  j 

The  degenerations  of  medullary  cancer  are  chiefly  three :  withering, 
fatty,  and  calcareous  degeneration.  Its  chief  diseases  are  equal  in 
number, — hemorrhage  or  apoplexy,  suppuration,  and  sloughing. 

A  medullary  cancer  may  gradually  decrease,  becoming  harder,  as  if 
by  shrivelling  and  condensing,  and  at  length  may  completely  disappear. 
I  have  mentioned  such  cases  at  p.  580 ;  and  I  have  seen  the  same 
happen  after  partial  removal  of  cancers. 

A  firm  medullary  tumor  was  seated  deep  in  the  substance  of  a  young 
woman's  parotid  gland.     Its  removal  with  the  knife  could  not  be  safely 

*  In  Series  xxxv,  No.  60,  in  the  Museum  of  St.  Bartholomew's,  is  a  large  medullary  tumor 
which  had  grown  in  the  subcutaneous  tissue  of  the  back,  and,  after  the  skin  over  it  had  ul- 
cerated, was  in  one  mass  squeezed  out  through  the  opening,  while  the  patient  was  endeavor- 
ing to  raise  herself  in  bed. 

f  Log.  cit.,  p.  375. 

J  A  probable  instance  is  related  by  Pirogoff  (Klinische  Chinirgie,  i,  p.  45).  It  was  in  a 
middle-aged  man.  The  tumor  grew  to  a  great  size,  and  appeared  connected  with  the 
periosteum  of  the  ribs ;  it  ulcerated,  sloughed  in  portions,  and  finally  healed.  The  patient 
remained  well  for  two  years,  at  least. 


588  MEDULLARY    CANCER. 

completed :  about  a  fourth  part  of  it  was  left  behind,  and  the  wound 
was  left  to  heal  in  the  ordinary  manner.  It  healed  quickly,  inclosing 
the  remains  of  the  tumor ;  but  after  some  time  all  the  appearance  of 
swelling  subsided,  and  no  renewed  growth  ensued  till  after  a  lapse  of 
three  months,  when  it  was  renewed,  but  not  more  rapidly  than  before. 

A  woman's  humerus  was  amputated  with  a  large  mass  of  firm  medul- 
lary cancer  surrounding  its  neck  and  the  upper  part  of  its  shaft.  The 
same  disease  existed  in  all  the  muscles  about  this  part  of  the  bone;  and 
the  patient  was  so  exhausted,  that  the  dissection  necessary  for  the  re- 
moval of  the  whole  disease  could  not  be  completed.  Large  portions  of 
it  were  left  in  the  deltoid  and  great  pectoral  muscles.  In  two  months 
after  the  operation,  however,  the  wound  had  very  nearly  healed,  and 
no  trace  could  be  felt  of  the  masses  of  the  cancer  in  the  muscles.  Nor 
did  any  perceptible  recurrence  take  place  till  more  than  four  months 
after  the  operation.  At  that  time  renewed  growths  appeared  at  the 
scar,  and  in  the  thyroid  gland,  and  quickly  increased. 

To  these  cases  I  might  add  at  least  three  in  which  I  have  known 
portions  of  cancerous  growths  left  in  the  orbit  after  incomplete  opera- 
tions ;  in  all  of  which  complete  healing  ensued,  and  one,  two,  or  three 
months  elapsed  before  any  renewed  growth  was  evident  in  the  portion 
of  disease  that  ^was  left.  In  all  these  cases  the  disappearance  of  the 
cancer  may  have  been  due  in  part  to  the  disease  and  rapid  degeneration 
excited  in  it  by  the  injury  of  the  operation  and  its  consequences ;  and 
in  all,  the  growth  was  renewed  Avithin  three  months  of  the  disappear- 
ance :  a  fallacious  hope  was  in  all  excited,  and  bitterly  disappointed. 
But  I  shall  have  presently  to  refer  to  a  case  in  which  the  removal  of 
cancers  was  independent  of  local  injury. 

It  is  most  probable  that  fatty  degeneration  coincided  with  the  wasting 
and  absorption  of  cancer  which  occurred  in  the  preceding  cases ;  for  it 
seems  to  be  the  most  frequent  change  when  growth  is  hindered.  I  have 
already  referred  to  the  fatty  degeneration  which,  in  medullary  cancers, 
as  in  other  tumors,  may  give  an  appearance  of  buff  or  ochre-yellow 
lines  or  minute  spots  scattered,  as  a  reticulum,  through  their  substance. 
I  have  also  described  (p.  564)  the  similar  but  larger  degeneration  which 
ensues  in  those  portions  or  lobes  of  medullary  cancers  that  are  found  as 
tuberculoid  masses  (phymatoid  of  Lebert),  yellow  and  half  dry,  among 
the  other  portions  that  appear  actively  progressive.  In  both  cases  it 
is  probable  that  the  altered  substances  are  incapable  of  further  growth  ; 
but  the  change,  being  only  partial,  does  not  materially  affect  the  pro- 
gress of  the  whole  mass.  But  though  more  rarely,  a  whole  mass  (espe- 
cially when  many  exist,  as  in  the  liver)  may  be  found  white,  or  yellow- 
ish-white, soft,  partially  dried,  close-textured  but  friable,  and  greasy 
to  the  touch — in  a  state  of  what  Rokitansky  has  called  "  saponifica- 
tion." In  such  cases,  many  of  the  cancer-cells  and  nuclei  have  the 
characters  of  the  granular  or  fatty  degeneration,  and  may  appear  col- 


DEGENERATION.  589 

lapsed  and  shrivelled  ;  and  they  are  mingled  with  abundant  molecular 
matter  and  oil-particles  of  various  sizes,  and  often  with  crystals  of  cho- 
lesterine  or  with  colored  granules.  All  the  analogies  of  such  changes 
in  other  parts  imply  that  cancers  thus  degenerated  must  be  incapable 
of  increase;  they  are  amongst  those  which  may  well  be  called,  as  by 
Rokitansky,  obsolete.  But  I  am  not  yet  sure  that  these  gradual 
changes  have  been  ever  followed  by  absorption  of  the  altered  cancer- 
substance,  and  by  healing  :*  the  disease  ceases  but  does  not  disappear  : 
and  usually,  while  one  mass  is  thus  changing,  others  are  progressive. 

The  calcarous  degeneration  is  much  more  rare  than  the  two  preceding. 
It  is  fully  described  by  Dr.  Bennettf  and  E,okitansky,|  and  is  in  all 
essential  characters  similar  to  that  which  so  often  occurs  in  degenera- 
ting arteries,  calcified  inflammatory  products,  &c.  The  earthy  matter, 
in  minute  granules,  is  commonly  mingled  with  fatty  matter,  and,  ac- 
cording to  the  quantity  of  fluid,  is  like  more  or  less  liquid  or  dry  and 
hardened  mortar  :  if  hardened  it  lies  in  grains,  or  larger  irregular  con- 
cretions, in  the  substance  of  the  tumor.  Its  indications  are  the  same 
as  those  of  the  fatty  degeneration  with  which  it  is  usually  mingled. § 

Among  the  diseases  of  medullary  cancers  their  proneness  to  bleeding 
may  be  mentioned.  Hence  their  occasionally  abundant  hemorrhages 
when  protruding,  and  the  frequent  large  extravasations  of  blood  in 
them,  variously  altering  their  aspects  as  it  passes  through  its  stages  of 
decolorization,  or  other  changes.  The  extreme  examples  of  such  bleed- 
ing cancers  constitute  the  fungus  hsematodes. 

Acute  inflammation  also  is  frequent,  especially  in  such  as  are  ex- 
posed through  ulcers.  It  may  produce  not  only  enlargement  of  the 
bloodvessels  and  swelling  of  the  tumor,  but  softening,  suppuration,  and, 
I  believe,  other  of  its  ordinary  eff"ects.  The  softening  may  be  com- 
pared with  that  which  occurs  in  inflammation  of  any  natural  part,  like 
which,  also,  it  is,  I  believe,  often  attended  with  a  rapid  fatty  degenera- 
tion or  a  disintegration  of  the  cancer-structures.  I  am  not  disposed  to 
think  with  Rokitansky  that  the  reticulum,  or  other  ordinary  yellow 
deposits  in  cancers,  are  due  to  inflammatory  exudations  passing  into 
and  propagating  a  fatty  transformation;  but  I  think  that  acute  inflam- 
mation in  a  medullary  or  any  other  cancer  is  likely  to  be  attended  with 

*  The  supposed  cases  of  healing  of  cancer  of  the  liver,  reported  as  having  occurred  at 
Prague,  admit  of  other  explanations.  (See  Lebert,  Traite  Pratique,  p.  72). 

f  On  Cancerous  and  Cancroid  Growths,  p.  214. 

X  Log.  cit..  p.  352. 

§  I  have  little  doubt  that  the  melanotic  cancer  might  be  truly  described  as  a  pigmental 
degeneration  of  the  medullary  cancer  (except  in  the  fevi^  instances  in  which  epithelial  can- 
cers are  melanotic).  But  part  of  another  lecture  will  be  devoted  to  this.  The  same  lecture 
will  comprise  the  colloid  or  alveolar  cancer;  and  I  shall  have  occasion  to  mention  in  it  the 
frequent  occurrence  of  cysts  in  medullary  cancers,  some  of  which  might  perhaps  be  de- 
scribed as  a  cystic  disease  of  the  cancers. 


590  MEDULLARY    CANCER. 

the  same  degenerative  softening  and  transformation  as  we  find  con- 
stituting a  part  of  the  inflammatory  process  in  the  natural  tissues. 
Thus  degenerating,  and  whether  with  or  without  suppuration,  a  medul- 
lary cancer  may  be  completely  removed. 

By  sloughing,  also,  a  medullary  cancer  may  be  wholly  ejected  ;  and 
this  event  is  more  likely  to  happen  than  with  any  other  kind  of  cancer, 
because  no  other  is  common  in  the  form  of  an  isolable  mass.  I  might 
collect  several  cases  in  which  it  has  occurred,  but  none  is  more  remark- 
able than  this.*  A  strong  man,  46  years  old,  under  Mr.  Lawrence's 
care,  had  a  large  firm  medullary  cancer  deep  seated  in  his  thigh,  of 
about  nine  months'  growth,  painful  and  increasing.  In  an  attempt  to 
remove  it,  the  femoral  artery  was  found  passing  right  through  it ;  its 
connections,  also,  appeared  so  wide  and  firm,  and  bleeding  ensued  from 
vessels  of  so  great  size,  that  the  operation  was  discontinued  after  about 
half  the  surface  of  the  tumor  had  been  uncovered.  The  tumor  sloughed, 
and  gradually  was  completely  separated.  It  came  away  with  nearly 
three  inches  of  the  femoral  artery  and  vein  that  ran  through  it.  No 
bleeding  occurred  during  or  after  the  separation,  and  the  cavity  that 
remained  in  the  thigh  completely  healed.  The  man  regained  an  appa- 
rently good  health  for  a  feAv  weeks  ;  then  the  disease,  returning  in  the 
thigh,  proved  quickly  fatal. 

In  the  following  strange  case,  nearly  all  the  methods  of  spontaneous 
temporary  cure  which  I  have  been  illustrating  were  exemplified : 

A  tall,  healthy-looking  man,  36  years  old,  came  under  my  care  in 
July,  1850.  In  October,  1849,  he  thought  he  strained  his  shoulder  in 
some  exertion,  and  soon  after  this  he  noticed  a  swelling  over  his  right 
deltoid  muscle.  It  increased  slowly  and  without  pain  for  nine  months, 
and  was  thought  to  be  a  fatty  tumor,  or  perhaps  a  chronic  abscess. 
About  the  beginning  of  July,  other  tumors  appeared  about  the  shoulder ; 
and,  when  I  first  saw  him,  there  was  not  only  the  tumor  first  formed, 
which  now  covered  two-thirds  of  the  deltoid,  but  around  its  borders 
were  numerous  smaller  round  and  oval  masses  ;  in  the  axilla  was  a  mass 
as  large  as  an  egg  ;  over  the  brachial  vessels  lay  a  series  of  five  smaller 
tumors,  and  a  similar  series  of  larger  tumors  over  the  axillary  vessels 
reaching  under  the  clavicle.  A  small  tumor  of  several  years'  date  lay 
at  the  border  of  the  sterno-mastoid  muscle ;  and  one,  which  had  been 
noticed  for  twelve  years,  was  in  the  right  groin.  All  these  tumors  were 
soft,  pliant,  painless,  subcutaneous,  movable,  more  or  less  lobed.  There 
could  be  very  little  doubt  that  they  were  medullary  cancers,  and  their 
complete  removal  seemed  impossible;  but  it  was  advised  that,  for  proof's 
sake,  one  should  be  excised.  I  therefore  removed  one  of  those  near  the 
chief  mass.  It  was  composed  of  a  soft  grayish  substance,  with  a  pale 
purple  tinge,  lobed,  easily  reduced  to  pulp,  and  in  microscopic  structure 

*  The  case  is  fully  reported  by  Mr.  Abernethy  Kingdon,  in  the  Medical  Gazette,  1850. 


TEMPORARY    CURE.  591 

consisted  almost  wholly  of  nucleated  cells  exactly  conformed  to  the  very 
type  of  cancer-cells.  The  operation  was  followed  by  no  discomfort ; 
and,  a  few  days  after  it,  the  patient  left  the  hospital,  still  looking 
healthy,  but,  I  supposed,  doomed  to  a  rapidly  fatal  progress  of  the  dis- 
ease. 

At  home,  near  Dover,  he  was  under  the  care  of  Mr.  Sankey.  In  a 
few  days  after  his  return,  the  skin  over  the  largest  tumor  cracked,  and 
a  thin  discharge  issued  from  it.  Four  days  later  he  was  attacked  with 
sickness,  diarrhoea,  and  abdominal  pain,  and  in  his  writhings  he  hurt 
his  arm.  Next  day,  three  or  four  more  openings  had  formed  over  the 
great  tumor,  and  the  scar  of  the  operation  wound  reopened  :  the  tumor 
itself  had  rapidly  enlarged.  From  all  these  apertures  pus  was  freely 
discharged,  and  in  a  day  or  two  large  sloughs  were  discharged  or  drawn 
through  them.  With  the  sloughing,  profuse  hemorrhage  several  times 
occurred.  All  the  upper  part  of  the  arm  and  shoulder  was  undermined 
by  the  sloughing,  and  a  great  cavity  remained,  from  which,  for  three 
weeks,  a  thin  foetid  fluid  was  discharged,  but  which  then  began  to  heal, 
and  in  twelve  weeks  was  completely  closed  in. 

While  these  changes  were  going  on  in  the  tumors  over  the  deltoid  and 
in  those  near  it,  that  in  the  axilla  was  constantly  enlarging.  It  became 
"  as  large  as  a  hat,"  and  early  in  September  it  burst ;  and  through  a 
small  aperture  about  six  pints  of  pus  were  rapidly  discharged.  A  great 
cavity,  like  that  of  a  collapsed  abscess,  remained;  but  it  quickly  ceased 
to  disch^ro-e,  and  healed.  In  the  same  time  all  the  tumors  over  the 
brachial  vessels  disappeared ;  they  did  not  inflame  or  seem  to  change 
their  texture ;  only,  they  gradually  decreased  and  cleared  away,  and 
with  them  that  also  disappeared  which  had  been  in  the  groin  for  twelve 
years. 

It  need  hardly  be  said  that  during  all  this  time  of  sloughing  and  sup- 
puration the  patient  had  been  well  managed,  and  amply  supported  with 
food  and  wine  and  medicine.  About  the  end  of  October  he  appeared 
completely  recovered,  and  returned  to  his  work.  I  saw  him  again  in 
January,  1851.  He  looked  and  felt  well,  and,  but  that  his  arm  was 
weak,  he  was  fully  capable  of  work  as  an  agricultural  laborer.  Over 
the  lower  half  of  the  deltoid  there  was  a  large  irregular  scar ;  and  this 
appeared  continuous  posteriorly  with  a  small  mass  of  hard  tough  sub- 
stance, of  which  one  could  not  say  whether  it  were  tissues  indurated 
after  the  sloughing,  or  the  remains  of  the  tumor  shrivelled  and  hard- 
ened:  whatever  it  was,  it  was  painless  and  gradually  decreasing.  No 
traces  remained  of  the  other  tumors  in  the  arm,  except  a  small  mass 
like  a  lymphatic  gland  in  the  middle  of  the  upper  arm.  In  the  axilla 
there  was  a  small  swelling  like  a  cluster  of  natural  lymphatic  glands. 
The  tumor  also  remained  at  the  border  of  the  sterno-mastoid  muscle, 
and  was  rather  larger  than  in  July. 

In  February,  1851,  the  swelling  of  the  axilla  began  to  increase,  its 


592  MEDULLARY    CANCER. 

growth  became  more  and  more  rapid.  By  the  end  of  March  the  arm 
was  greatly  swollen ;  he  suffered  severe  pain  in  and  about  it ;  his  health 
failed ;  he  had  dyspnoea  and  frequent  vomiting,  and  died  with  pleuro- 
pneumonia on  April  20.  The  tumor  in  the  axilla  (the  only  one  found 
after  death)  was  about  eight  inches  long,  oval,  lobed,  soft,  vascular,  and 
brain-like,  and  consisted,  chiefly,  of  small  apparently  imperfectly 
formed  cancer-cells. 

Such  a  case  as  this  needs  little  comment.  It  illustrates  the  spon- 
taneous removal,  and,  so  far,  the  healing,  of  medullary  cancers  by  ab- 
sorption, by  inflammation  and  abundant  suppuration,  and  by  sloughing. 
It  shows  the  absorption  of  the  cancerous  matter,  doubtless  in  an  altered 
state,  accomplished  without  evident  injury  to  the  economy.  And  it 
illustrates  the  cancerous  diathesis  quickly  re-established  after  being,  we 
must  suppose,  suspended  or  superseded  for  a  time,  during  the  removal 
of  its  products.  Hard,  therefore,  as  we  may  say,  the  struggle  for  re- 
covery was,  it  was  not  successful. 

It  is  scarcely  possible  to  give  general  illustrations  of  the  pain  and 
other  phenomena  attendant  on  the  progress  of  medullary  cancers  ;  for 
these  are  variously  modified  by  the  many  organs  in  which  it  may  have 
its  primary  seat.  The  history  of  some  of  the  medullary  cancers,  which 
grow  as  distinct  tumors,  may  teach  us  that  the  pain  is  not  an  affection 
of  the  cancer  itself,  but  of  the  organ  which  it  occupies.  Such  cancer- 
ous tumors,  in  the  subcutaneous  areolar  tissue,  are,  I  believe,  rarely  the 
sources  of  jjain  ;  often  they  are  completely  insensible  :  yet  the  same 
kind  of  tumors  seated  among  the  deeper  parts  of  limbs,  or  inclosed  in 
the  testicle,  or  in  bone,  seem  to  be  usually  painful,  and  often  severely 
so.  The  difference  indicates  that  the  varying  pain  is  not  of  the  cancer, 
but  of  the  part  it  fills. 

The  cachexia  is,  in  the  later  periods  of  the  disease,  too  much  varied 
by  the  disturbed  functions  of  the  organs  specially  affected  to  admit  of 
general  description.  But  it  is  chiefly  in  this  form  of  cancer  that,  early 
in  the  disease,  and  even  while  the  local  affection  seems  trivial,  and  in- 
volves no  important  part,  we  often  find  the  signs  of  the  general  health 
being  profoundly  affected  ;  the  weight  and  muscular  power  regularly 
diminishing,  the  complexion  gradually  fading,  the  features  becoming 
sharper,  the  pulse  and  breathing  quicker,  the  blood  more  pale.  Such 
events  are,  indeed,  inconstant,  both  in  the  time  of  their  occurrence  and 
in  their  intensity ;  but  in  many  cases  they  are  far  too  striking  to  be 
overlooked ;  the  defective  nutrition  of  the  early  stages  of  phthisis  is 
not  more  marked :  the  evidence  is  complete  for  the  proof  of  a  distinct 
cancerous  cachexia,  which  is  indeed  commonly  indicated  and  may  be 
measured  by  a  cancerous  growth,  but  which  may  exist  in  a  degree,  with 
which  neither  the  bulk,  nor  the  rate  of  increase,  of  the  growth  is  at  all 
commensurate. 

To  estimate  the  general  duration  of  life  in  those  who  have  medullary 


DURATION    OF    LIFE.  593 

cancers,  those  cases  alone  should  be  reckoned  in  which  parts  whose 
functions  are  not  essential  to  life  are  affected ;  such  as  the  hones  and 
soft  parts  about  the  trunk  and  limbs,  the  testicle,  the  eye,  and  other 
external  organs.  From  a  table  of  fifty  cases  of  medullary  cancers  in 
these  parts  (including  eight  cases  of  cancer  of  the  bones  by  M.  Lebert), 
in  all  of  which  the  disease  pursued  its  course  without  operative  inter- 
ference, I  find  the  average  duration  of  life  to  be  rather  more  than  two 
years  from  the  patient's  first  observation  of  the  disease.* 
Among  45  of  these  patients, 


6  died  within 

6  months. 

7     "     between 

6  and  12 

months. 

11     " 

12    "     18 

" 

4     « 

18    "    24 

" 

7     " 

24    "     36 

" 

7     " 

36    "    48 

" 

3     "  more  than 

48  months 

from  the  commencement  of  the  disease. 

A  comparison  of  this  table  with  that  at  p.  555  will  show,  in  striking 
contrast  with  the  history  of  scirrhous  cancer,  the  rapidity  of  this  form 
in  running  its  fatal  career ;  a  rapidity  which  is  certainly  not  to  be 
ascribed  to  the  earlier  exhaustion  produced  by  hemorrhage,  discharge, 
pain,  or  other  local  accidents  of  the  disease,  but  is  mainly  due  to  the 
augmenting  cachexia.  The  same  comparison  will  show  how  small  is 
the  proportion  of  those  in  whom  the  disease  lasts  more  than  four  years  ; 
and  there  seem  to  be  no  cases  parallel  with  those  of  scirrhous  cancer 
which  are  slowly  progressive  through  periods  of  five,  ten,  or  more  years. 
I  have  mentioned  instances  of  the  apparent  suspension  of  the  disease ; 
but  these  are  different  from  the  cases  of  constant  slow  progress,  the 
rarity  of  which  supplies  an  important  fact  in  diagnosis,  in  the  great 
probability  that  a  tumor  is  not  a  medullary  cancer,  if  it  have  been  in- 
creasing for  more  than  three  years  without  distinct  manifestation  of  its 
cancerous  nature. 

The  effect  of  removing  medullary  cancers  is,  on  the  whole,  an  in- 
creased average  duration  of  life ;  but  chiefly,  I  believe,  because  in  a 
few  cases  the  operation  is  long  survived,  and,  in  some,  death,  which 
would  have  speedily  ensued,  is  for  a  time  arrested.  Thus  in  forty-six 
cases  in  which  external  medullary  cancers  were  removed  by  excision, 
or  amputation  of  the  affected  part,  the  average  duration  of  life  was 
something  more  than  twenty-eight  months. f  Among  fifty-one  cases 
(including  nine  cases  of  extirpated  cancer  of  the  eye,  from  M.  Lebert), 

*  I  have  not  reckoned  in  this  table  the  exceptional  cases  referred  to  at  p.  586,  in  which 
the  disease  appears  to  have  been  suspended  for  some  years.  But  I  have  included  five 
cases  in  which  the  patients  were  still  living  beyond  the  average  time.  In  the  forty-five 
already  dead,  the  average  duration  of  life  was  23.8  m.onths. 

f  Two  of  Mr.  Baker's  tables  show  a  greater  advantage  derived  from  operations,  probably 
because  of  a  better  selection  of  cases.  The  average  duration  of  life  in  32  cases  not  sub- 
mitted to  operation  was  20  months ;  in  16  cases  operated  on,  33.4  months. 


594 


MEDULLARY    CANCER. 


these  were  the  several  times  of  death,  reckoning,  as  before,  from  the 


ot  the 

Witliin 

disease  t 

6  months, 

)j  the  patient : 

.        1 

Between 

6  and  12 

months, 

.     13 

" 

12 

'     18 

.       7 

" 

18 

'    24 

.       8 

i: 

24 

'     36 

.      11 

" 

36 

'    48 

.       3 

Above 

4S 

8 

The  comparison  of  this  table  with  that  on  p.  593  will  show  that  the 
only  notable  contrast  between  them  is  in  their  first  and  last  lines. 

If  the  operation  be  recovered  from,  the  regular  course  of  events 
brings  about  the  renewal  of  cancerous  growth,  either  near  the  seat  of 
the  former  growth,  or  in  the  lymphatics  connected  therewith,  or,  more 
rarely,  in  some  distant  part.  In  thirty-eight  cases  of  medullary  cancer, 
affecting  primarily  the  same  external  organs  as  afforded  the  cases  for 
the  former  tables,  I  find  the  average  period  of  recurrence  after  the 
operation  to  have  been  seven  months.  I  have  reckoned  only  those  cases 
in, which  a  period  of  apparent  recovery  was  noted  after  the  operation  ; 
all  those  cases  are  omitted  in  which  the  disease  was  not  wholly  removed, 
or  in  which  it  is  most  probable  that  the  same  disease  existed  unobserved 
in  lymphatics  or  other  internal  organs  at  the  time  of  operation.  Yet 
the  average  rate  of  recurrence  is  fearfully  rapid. 

It  was  observed  in  between 

1  and     3  months  in  18  cases. 

3    "       6  "  11       " 

6    "     12  "  4      " 

12    "     24  "  3       " 

24    "     36  "  2       " 


Among  the  fifty-one  cases  in  the  first  table  above,  those  of  five  pa- 
tients are  included,  who  were  living  without  apparent  return  of  disease^ 
for  periods  of  three,  three  and  a  half,  four  and  a  half,  five,  and  six 
years  after  operation ;  and  I  have  referred  already  to  one  case  in  which 
a  patient  died  with  cancer  in  the  pelvis  twelve  years  after  the  removal 
of  a  testicle  which  was  considered  cancerous.  Of  cases  more  near  to 
recovery  than  these  I  can  find  no  instances  on  authentic  record. 

The  cases  I  have  been  able  to  collect  supply  little  that  is  conclusive 
respecting  the  different  durations  of  life,  according  to  the  age  of  the 
patient,  the  seat  of  the  cancer,  and  other  such  circumstances.  In  chil- 
dren under  ten  years  old,  the  average  duration  of  life,  with  medullary 
cancers  of  external  parts,  is,  I  believe,  not  more  than  eighteen  months ; 
after  ten  years,  age  seems  to  have  little  or  no  influence.  According  to 
the  part  affected  the  average  duration  of  life  appears  to  be  greater  in 
the  following  order  :  the  testicle,  the  eye,  the  bones,  the  soft  parts  of 
the  limbs  and  trunk,  the  lymphatics  ;  but  the  difference  is  not  consider- 


DURATION     OF     LIFE.  595 

able.  It  is  the  same,  I  believe,  "vvith  the  results  of  operations ;  recur- 
rence and  death  occur,  on  the  whole,  more  tardily  after  amputations  for 
medullary  cancers  of  the  bones  and  soft  parts  of  the  limbs,  than  after 
extirpations  of  the  eye  or  testicle ;  but  there  are  many  obvious  reasons 
why  we  cannot  hence  deduce  more  than  a  very  unstable  rule  for  prac- 
tice. The  previous  duration  of  the  disease  seems,  also,  to  have  little 
influence  on  the  time  of  recurrence  after  the  operation :  the  only  gene- 
ral rule  seems  to  be,  that  the  rapidity  of  recurrence  corresponds  with 
that  of  the  progress  of  the  primary  disease. 

Now,  respecting  the  propriety  of  removing  a  medullary  cancer  in  any 
single  case,  much  that  was  said  respecting  the  operation  for  scirrhous 
cancer  of  the  breast  might  be  repeated  here.  The  hope  of  finally  curing 
the  disease  by  operation  should  not  be  entertained.  Such  an  event  may 
happen,  but  the  chance  of  it  is  not  greater  than  that  of  the  disease 
being  spontaneonsly  cured  or  arrested  ;  and  the  chance  of  any  of  these 
things  is  too  slight  to  be  weighed  in  the  decision  on  any  single  case. 
The  question,  in  each  case,  is  whether  life  may  be  so  prolonged,  or  its 
sufferings  so  diminished,  as  to  justify  the  risk  of  the  operation.  In 
general,  I  think,  the  answer  must  be  affirmative  wherever  the  disease 
can  be  wholly  removed,  and  the  cachexia  is  not  so  manifest  as  to  make 
it  most  probable  that  the  operation  will  of  itself  prove  fatal. 

(1.)  The  number  of  cases  in  which  the  patients  survive  the  operation 
for  a  longer  time  than  that  in  which,  on  the  average,  the  disease  runs 
its  course,  is  sufficient  to  justify  the  hope  of  considerable  advantage 
from  the  removal  of  the  disease.  On  the  other  hand,  the  number  of 
chronic  cases  of  medullary  cancer  is  so  small,  that  no  corresponding 
hope  of  a  life  being  prolonged  much  beyond  the  average  can  be  reason- 
ably held,  if  the  disease  be  left  to  run  its  own  career.* 

(2.)  The  hope  that  the  removal  of  the  cancer  will  secure  a  considera- 
ble addition  (two  or  more  years,  for  example,)  to  the  length  of  life  will 
be  more  often  disappointed  than  fulfilled.  But,  even  when  we  do  not 
entertain  this  hope,  the  operation  may  be  justified  by  the  belief  that  it 
will  avert  or  postpone  great  suffering.  The  miseries  attendant  on  the 
regular  progress  of  a  medullary  cancer,  in  any  external  part,  are  hardly 
less  than  those  of  hard  cancer  of  the  breast ;  they  are  such,  and  in 
general  so  much  greater  than  those  of  the  recurrent  disease,  that  unless 
it  is  very  probable  that  an  operation  will  materially  shorten  life,  its 
performance  is  warranted  by  the  probability  of  its  rendering  the  rest 
of  life  less  burdensome. 

(3.)  A  motive  for  operation  in  cases  of  supposed  medullary  cancers 
may  often  be  drawn  from  the  uncertainty  of  the   diagnosis.     This  is 

*  The  difference  here  stated  may  seem  opposed  by  the  tables  in  the  foregoing  pages.  I 
must  therefore  state  that,  at  page  586,  I  have  referred  to  all  the  cases  of  chronic  or  sus- 
pended medullary  cancer  that  I  have  ever  seen  or  heard  of;  but  that  the  cases  of  operations 
survived  for  more  than  three  years,  mentioned  at  page  594,  were  not  selected  on  this 
account,  but  occurred  in  the  ordinary  course  of  observation. 


596  EPITHELIAL    CANCER. 

especially  the  case  with  those  of  the  large  bones,  for  the  removal  of 
which  the  peril  of  the  necessary  operation  might  seem  too  great  for  the 
probability  of  advantage  to  be  derived  from  it.  I  have  referred  to 
cases  of  cartilaginous  and  myeloid  tumors  of  bone  (pp.  443,  463,  466), 
in  which  during  life  the  diagnosis  from  medullary  cancers  was,  I  be- 
lieve, impossible.  In  all  such  cases,  and  I  am  sure  they  are  not  very 
rare,  the  observance  of  a  rule  against  the  removal  of  tumors  or  of  bones 
believed  to  be  cancerous,  would  lead  to  a  lamentable  loss  of  life.  All 
doubts  respecting  diagnosis  are  here  to  be  reckoned  in  favor  of  opera- 
tions. 


LECTURE    XXXII. 

EPITHELIAL  CANCEK. 

PAET    I. — ANATOMY. 

Epithelial  cancer  has  its  primary  seat,  with  very  rare  exceptions, 
in  or  just  beneath  some  portion  of  skin  or  mucous  membrane.  Its  most 
frequent  locality  is  the  lower  lip,  at  or  near  the  junction  of  the  skin 
and  mucous  membrane ;  next  in  order  of  frequency  it  is  found  in  the 
tongue,  prepuce,  scrotum  (of  chimney-sweeps),  labia,  and  nymphse : 
more  rarely  it  occurs  in  very  many  other  parts, — as  at  the  anus,  in  the 
interior  of  the  cheek,  the  upper  lip,  the  mucous  membrane  of  the  palate, 
the  larynx,  pharynx,  and  cardia,  the  neck  and  orifice  of  the  uterus,  the 
rectum  and  urinary  bladder,  the  skin  of  the  perineum,  of  the  extremi- 
ties, the  face,  head,  and  various  parts  of  the  trunk.  In  the  rare 
instances  of  its  occurrence,  as  a  primary  disease,  in  other  than  integu- 
mental  parts,  it  has  been  found  in  the  inguinal  lymphatic  glands  (as  in 
a  case  which  I  shall  relate),  in  bones,*  the  dura  mater,  and  in  the 
tissues  forming  the  bases  or  walls  of  old  ulcers. 

By  extension  from  any  of  its  primary  seats,  an  epithelial  cancer  may 
occupy  any  tissue :  thus,  in  its  progress  from  the  lip,  tongue,  or  any 
other  part,  muscles,  bones,  fibrous  tissues,  are  alike  invaded  and  de- 
stroyed by  it.  As  a  secondary  disease,  or  in  its  recurrence  after  re- 
moval by  operation,  it  may  also  have  its  seat  in  any  of  these  tissues  at 
or  near  its  primary  seat ;  but  it  more  commonly  affects  the  lymphatic 
glands  that  are  in  anatomical  connection  therewith ;  and,  very  rarely, 
it  has  been  found  in  internal  organs,  the  lungs,  liver,  and  heart. f 

*  Virchow,  in  the  Wiirzburg  Verhandluna;en,  i,  106. 

f  In  the  lungs  and  in  the  heart,  in  the  Museum  of  St.  Bartholomew's.  In  the  liver  once, 
by  Rokitansky  (Pathol.  Anat,  i,  386).  In  the  lungs  and  in  the  liver,  in  the  Museums  of 
Berlin  and  Wiirzburg  (Virchow,  1.  c. ;  and  in  his  Archiv,  B.  iii,  p.  222).  Ch.  Robin  has 
described,  under  the  title  epithelioma  of  the  kidney  (Gaz.  des  Hop.,  1855),  a  well-marked 


ANATOMY STRUCTURE.  597 

The  essential  anatomical  character  of  the  epithelial  cancer  is,  that  it 
is  chiefly  composed  of  cells  which  bear  a  general  resemblance  to  those 
of  such  tessellated  or  scaly  epithelium  as  lines  the  interior  of  the  lips 
and  mouth,*  and  that  part  of  these  cells  are  inserted  or  infiltrated  in  the 
interstices  of  the  proper  structures  of  the  skin  or  other  affected  tissue.f 

The  epithelial  cancers  of  the  skin  or  mucous  membrane  from  which, 
as  types,  the  general  characters  of  the  disease  must  be  drawn,  present 
many  varieties  of  external  shape  and  relations,  which  are  dependent, 
chiefly,  on  the  situation  in  which  the  cancerous  structures  are  placed. 
They  may  be  either  almost  uniformly  diffused  among  all  the  tissues  of 
the  skin  or  mucous  membrane,  predominating  in  only  a  small  degree  in 
the  papillae  ;  or  the  papillae  may  be  their  chief  seat ;  or  they  may  oc- 
cupy only  the  subintegumental  tissues.  As  a  general  rule,  in  the  first 
of  these  cases,  the  cancer  is  but  little  elevated  above  or  imbedded  below 
the  normal  level  of  the  integument,  and  its  depth  or  thickness  is  much 
less  than  its  other  dimensions  ;  in  the  second,  it  forms  a  prominent 
warty  or  exuberant  outgrowth  ;  in  the  third,  a  deeper-seated  flat  or 
rounded  mass.  These  varieties  are  commonly  Avell  marked  in  the  first 
notice  of  the  cancers,  or  during  the  earlier  stages  of  their  growth  ;  later, 
they  are  less  marked,  because  (especially  after  ulceration  has  com- 
menced) an  epithelial  cancer,  which  has  been  superficial  or  exuberant, 
is  prone  to  extend  into  deep-seated  parts ;  or  one  which  was  at  first 
deeply  seated  may  grow  out  exuberantly.  Moreover,  when  ulceration 
is  in  progress,  a  greater  uniformity  of  external  appearance  is  found ; 
for,  in  general,  while  all  that  was  superficial  or  exuberant  is  in  process 
of  destruction,  the  base  of  the  cancer  is  constantly  extending  both 
widely  and  deeply  into  the  subintegumental  tissues. 

I  believe  that  it  will  be  useful  to  describe  separately  the  external 

case  of  epithelial  cancer  of  the  kidney,  but  under  the  same  title  he  describes  a  case  which 
appears  to  have  been  nothing  more  than  blocking  up  with  epithelium  and  dilatation  of  the 
urine  tubes.  In  a  case  described  by  Mr.  Sibley  in  the  Path.  Trans.,  vol.  x,  p.  272,  in  which 
the  tongue  was  affected  with  epithelial  cancer,  a  post-mortem  examination  disclosed  a 
peculiar  condition  of  the  right  supra-renal  capsule.  It  was  enlarged  and  converted  into  a 
firm,  almost  fibrous-looking,  cream-colored  substance,  in  which  "  large  numbers  of  cells, 
closely  resembling  epithelial  cancer-cells,  were  found."    The  other  viscera  were  healthy. 

*■  In  very  rare  cases  the  cells,  or  part  of  them,  are  like  those  of  columnar  epithelium. 

f  In  assigning  these  two  conditions  as  the  essential  characters  of  epithelial  cancers — 
namely,  both  the  construction  with  epithelial  cells,  and  the  insertion  of  such  cells  among  the 
original,  though  often  morbid,  textures  of  the  affected  part — I  make  a  group  of  diseases  less 
comprehensive  than  either  the  "  Cancroid''  of  Lebert  and  Bennett,  or  the  "Epithelioma"  of 
Hannover.  These  excellent  pathologists,  and  many  others  following  them,  would  abolish 
altogether  the  name  of  epithelial  cancer,  and  place  the  cases  which  are  here  so  designated 
in  a  group  completely  separate  from  cancers,  as  exemplified  by  the  scirrhous  and  medullary 
forms.  It  is  not  without  much  consideration  that  I  have  decided  to  ditfer  from  such  authori- 
ties ;  but  I  believe  that  the  whole  pathology  of  the  diseases  in  which  the  two  characters  above 
cited  are  combined  is,  with  rare  exceptions,  so  closely  conformed  to  that  of  the  scirrhous  and 
medullary  cancers,  that  they  should  be  included  under  the  same  generic  name.  The  grounds 
of  this  belief,  which,  I  think,  agrees  with  the  opinions  of  Rokitan,sky  and  Virchow,  will  ap- 
pear in  the  present  lecture  ;  and  at  its  end  I  will  briefly  sum  them  up. 


598  SUPERFICIAL     EPITHELIAL     CANCER. 

characters  of  the  two  principal  varieties  of  epithelial  cancer  of  the  in- 
teguments here  indicated  ;  and  (while  remembering  that  mingled,  transi- 
tional, and  intermediate  specimens  may  be  very  often  seen),  to  speak 
of  them  as  the  superficial  or  outgrowing,  and  the  deep-seated,  forms  of 
the  disease.* 

Among  the  examples  of  the  superficial  epithelial  cancers,  the  greater 
part  derive  a  peculiar  character  from  the  share  which  the  papillae  of  the 
skin  or  mucous  membrane  take  in  the  disease.  These  being  enlarged, 
and  variously  deformed  and  clustered,  give  a  condylomatous  appear- 
ance to  the  morbid  structures,  which  has  led  to  their  being  called  papil- 
lary or  warty  cancers,  and  which  renders  it  sometimes  difficult  to 
distinguish  them  from  common  warty  growths.  According  to  the 
changes  in  the  papillae,  numerous  varieties  of  external  appearance  may 
be  presented  :  I  shall  here  describe  only  the  chief  of  them. 

In  the  most  ordinary  examples  of  epithelial  cancer  of  the  lower  lip, 
or  of  a  labium,  or  of  the  scrotum  in  the  soot-cancers,  if  they  be  ex- 
amined previous  to  ulceration,  one  can  feel  an  outspread  swelling,  and 
an  unnatural  firmness  or  hardness  of  the  afiected  skin.  The  width  and 
length  of  the  swelling  are  much  greater  than  its  thickness.  The  diseased 
part  is  enlarged  ;  the  lip,  for  example,  pouts,  and  projects  like  one 
overgrown  ;  and  the  swelling  is  slightly  elevated,  rising  gradually  or 
abruptly  from  its  borders,  and  having  a  round  or  oval  or  sinuous  out- 
line. Its  surface,  previous  to  ulceration,  may  be  nearly  smooth,  but 
more  often  is  coarsely  granulated,  or  tuberculated,  or  lowly  warty,  like 
the  surface  of  a  syphilitic  condyloma,  deriving  this  character  usually 
from  the  enlarged  and  closely  clustered  papillae.  The  surface  is  gene- 
rally moist  with  ichorous  discharge,  or  covered  with  a  scab,  or  with  a 
soft  material  formed  of  detached  epidermal  scales.  The  firmness  or 
hardness  of  the  diseased  part  is  various  in  degree  in  different  instances  : 
it  is  very  seldom  extreme  ;  the  part,  however  firm,  is  usually  flexible 
and  pliant,  and  feels  moderately  tense  and  resilient  on  pressure.  Com- 
monly, it  is  morbidly  sensitive,  and  the  seat  of  increased  afilux  of  blood. 
Its  extent  is,  of  course,  various ;  but,  before  ulceration,  the  disease 
makes  more  progress  in  length  and  breadth  than  in  depth  ;  so  that 
Avhen,  for  example,  it  occupies  the  whole  border  of  a  lip  or  of  a  labium, 
it  may  not  exceed  the  third  of  an  inch  in  thickness. 

In  the  form  of   epithelial  cancer   just  described  there  may  be  no 

*  I  believe  that  either  of  these  forms  may  occur  in  any  of  the  parts  enumerated  as  the 
usual  seats  of  epithelial  cancer ;  but  they  are  not  both  equally  common  in  every  such  part. 
The  superficial,  and  especially  those  which  have  the  characters  of  warty  and  cauliflower- 
like outgrowths,  are  most  frequently  founii  on  mucous  surfaces,  especial  those  of  the  genital 
organs  ;  the  deep-seated  are  more  frequent  in  the  tongue  than  elsewhere  ;  those  on  the  ex- 
tremities and  in  the  scrotum  have  usually  a  well-marked  warty  character,  and  are  rarely 
deep-seated.  Other  particulars  might,  I  believe,  be  stated,  but  1  am  unwilling  to  state  them 
unsupported  by  counted  niunbers  of  cases. 


VARIETIES. 


599 


considerable  enlargement  of  papillae,  or  it  may  only  appear  when  the 
growth  is  cut  through.  But,  in  many  instances  (especially,  I  think,  in 
the  epithelial  cancers  of  the  prepuce,  glands,  and  integuments  of  the 
extremities),  the  changes  of  the  papilla  are  much  more  evident.  In 
some,  as  in  the  adjacent  sketch,  one  sees  a  great  extent  of  surface  covered 
with  crowds  and  clusters  of  enlarged  papillae  set  on  a  level  or  slightly 

Fie;.  98.* 


elevated  portion  of  the  cutis.  Singly  (when  the  ichor  and  loose  scales 
that  fill  their  intervals  are  washed  away),  they  appear  cylindriform, 
flask-shaped,  pyriform,  or  conical ;  clustered,  they  make  nodulated  and 
narrow-stemmed  masses.  They  may  be  in  one  or  in  many  groups  ;  or 
groups  of  them  may  be  scattered  around  some  large  central  ulcer.  They 
appear  very  vascular,  and  their  surface,  thinly  covered  with  opaque- 
white  cuticle,  has  a  pink,  or  vermilion,  or  brightly  florid  hue.f 

In  other  instances,  or  in  other  parts,  a  large  mass  is  formed,  the  sur- 
face of  which,  when  exposed  by  washing  away  the  loose  epidermoid 
cells  which  fill  up  its  inequalities,  is  largely  granulated  or  tuberculated, 
and  is  planned  out  into  lobes  by  deeper  clefts.  Such  growths  are  up- 
raised, cauliflower-like;  and,  with  this  likeness,  may  be  broken  through 
the  clefts,  into  narrow-stemmed  masses,  formed  each  of  one  or  more 
close-packed  groups  of  enlarged,  tuberous,  and  clavate  papillae. |  The 
surface  of  such  a  growth  shows,  usually,  its  full  vascularity;  for  if  it  be 
washed,  it  appears  bare,  and,  like  the  surface  of  common  granulations, 
has  no  covering  layer  of  cuticle.  It  may  be  florid,  bleeding  on  slight 
contact,  but,  more  often,  it  presents  a  dull  or  rusty  vermilion  tint,  rather 


*  The  papillary  character  is  well  shown  in  the  specimen  of  soot-cancer  of  the  hand,  in 
the-Museum  of  St.  Bartholomew's  (Ser.  xi,  6),  which  is  represented  in  Fig.  98.  The  history 
of  the  case  is  in  Pott's  Works  by  Earle,  iii,  182.  The  patient  was  a  gardener,  who  had  been 
employed  in  strewing  soot  for  several  mornings:  the  disease  was  of  five  years'  duration. 

t  Museum  of  St.  Bartholomew's,  Ser.  i,  42,  126,  127,  &c.,  and  Ser.  xi,  6.  Mus.  Coll.  Surg.. 
2301,2607,  2608,  &c. 

X  Museum  of  St.  Bartholomew's,  Ser.  xxx,  35.     Mus.  Coll.  Surg.  2609. 


600  SUPERFICIAL    EPITHELIAL     CANCER. 

than  the  brighter  crimson  or  pink  of  common  granulations,  or  of  such 
Avarts  as  one  commonly  sees  on  the  prepuce  or  glans  penis. 

Occasionally,  we  meet  with  an  epithelial  cancer  having  the  shape  of 
a  sharply  bordered  circular  or  oval  disk,  upraised  from  one  to  three 
lines  above  the  level  of  the  adjacent  skin  or  mucous  membrane,  and  im- 
bedded in  about  the  same  depth  below  it.  The  surfaces  of  such  disk- 
shaped  cancers  are  usually  flat,  or  slightly  concave,  granulated,  spongy, 
or  irregularly  cleft ;  their  margins  are  bordered  by  the  healthy  integu- 
ments, raised  and  often  slightly  everted  by  their  growth.  Such  shapes 
are  not  unfrequent  among  the  epithelial  cancers  of  the  tongue,  of  the 
lining  of  the  prepuce,  and  of  the  scrotum.  I  removed  such  a  one  also 
from  the  perineum,  and  have  seen  one  in  the  vagina. 

SometimiCS,  again,  an  epithelial  cancer  grows  out  in  the  form  of  a 
cone.  I  examined  such  a  one  removed  from  the  lower  lip,  which  was 
half  an  inch  high,  and  nearly  as  much  in  diameter  at  its  base.  Its  base 
was  a  cancerous  portion  of  cutis ;  its  substance  was  firm,  gray,  com- 
posed of  the  usual  elements  of  epithelial  cancers  imbedded  among  the 
connective  tissue  outgrown  from  the  skin ;  the  subcutaneous  tissue  was 
healthy.  In  another  instance  an  exactly  similar  cancer  grew  on  a  chim- 
ney-sweep's neck;*  and,  in  both  these  cases,  the  growth  being  covered 
with  a  thick  laminated  black  and  brown  scab,  was,  at  first,  not  easy  to 
distinguish  from  syphilitic  rupia :  that  in  the  neck  might  even  have 
been  confounded  (as  some,  I  believe,  have  been)  with  one  of  the  horns 
that  grow  from  diseased  hair  follicles.  Mr.  Curlingf  describes  a  simi- 
lar growth  three  quarters  of  an  inch  long,  on  the  scrotum  of  a  chimney- 
sweep ;  and  has  copied,  from  one  of  Mr.  Wadd's  sketches,  a  representa- 
tion of  a  horn  two  and  a  half  inches  long  similarly  formed. 

Lastly,  Ave  may  find  epithelial  cancers  as  narrow-stemmed  or  even 
pendulous  growths  from  the  cutis.     I  have  seen  such 
Fig.  99.  J  Qjj  ^]^g  loAver  lip,  and  at  the  anus,  like  masses  of  very  ' 

firm  exuberant  granulations,  two  inches  in  diameter, 
springing  from  narroAV  bases  in  the  cutis,  or  deeper 
tissues,  and  far  overhanging  the  adjacent  healthy  skin. 
And  I  lately  examined  one  of  this  kind,  which  was 
removed  from  the  skin  over  the  lower  border  of  the 
great  pectoral  muscle.  It  was  exactly  like  the  speci- 
men sketched  in  Fig.  99.  It  was  spheroidal,  about 
an  inch  in  diameter,  rising  from  the  skin  with  a  base 

*  Mus.  of  St.  Bartholomew's.  In  the  next  year  the  same  patient  was  in  the  hospital  with 
a  cancerous  wart  of  the  scrotum. 

f  Treatise  on  Diseases  of  the  Testicle,  p.  -522.  The  specimen  is  in  the  Mus.  Coll.  Surg. 
2469.  In  the  Museum  of  St.  Bartholomew's  is  an  instance  of  very  large  soot-cancer,  in  which, 
at  the  borders  of  the  ulcer,  there  are  spur-shaped  sharp-pointed  processes,  doubtless  cancerous 
papillae,  some  of  which  are  from  \  to  J  an  inch  in  length. 

J  Fig.  99.  Section  of  a  narrow-based  outgrowing  epithelial  cancer.  It  was  extremely 
vascular,  and  had  grown  in  the  place  of  a  dark  mole,  or  pigmentary  nsevus,  on  the  wall  of 
the  abdomen.     Two  growths  had  been  previously  removed  from  the  same  part. 


EXTERNAL    CHARACTERS.  601 

about  half  as  wide ;  it  was  lobed,  deeply  fissured,  and  subdivided  like 
a  wart,  with  its  component  portions  pyriform  and  mutually  compressed. 
Its  surface  was  pinkish,  covered  with  a  thin  opaque-white  cuticle,  which 
extended  into  and  seemed  to  cease  gradually  in  the  fissures.  Its  sub- 
stance, composed  almost  wholly  of  epithelial  cancer-cells,  was  mode- 
rately firm  and  elastic.  It  was  but  little  painful.  A  thin,  strong- 
smelling  fluid  oozed  from  it.  The  patient  had  noticed  a  small  un- 
changing wart  in  the  place  of  this  growth  for  ten  or  twelve  years. 
Without  evident  cause  it  had  begun  to  grow  rapidly,  and  had  become 
redder  and  discharged  fluid,  six  weeks  before  its  removal.* 

It  is  almost  needless  to  say  that  a  much  greater  variety  of  shapes 
than  I  have  here  described  may  be  derived  from  the  different  methods 
and  degrees  in  which  the  papillae  are  deformed,  enlarged,  and  involved 
in  the  cancerous  disease.  All,  and  more  than  all,  the  shapes  of  common 
warty  and  condylomatous  growths  may  be  produced.  But  the  same 
general  plan  of  construction  exists  in  all ;  namely,  a  certain  portion  of 
the  skin  or  mucous  membrane  is  infiltrated  with  epithelial  cancer-struc- 
tures :  on  this,  as  on  a  base  more  or  less  elevated  and  imbedded,  the 
papillae,  variously  changed  in  shape,  size,  and  grouping,  are  also  can- 
cerous ;  their  natural  structures,  if  we  except  their  bloodvessels,  which 
appear  enlarged,  are  replaced  by  epithelial  cancer-cells.  And  herein 
is  the  essential  distinction  between  a  simple  or  common  warty  or  papil- 
lary growth,  and  a  cancerous  one  or  warty  cancer.  In  the  former  the 
papillae  retain  their  natural  structures  ;  however  much  they  may  be 
multiplied,  or  changed  in  shape  and  size,  they  are  either  merely  hyper- 
trophied,  or  are  infiltrated  with  organized  inflammatory  products ; 
however  abundant  the  epidermis  or  epithelium  may  be,  it  only  covers 
and  ensheaths  them.  But  in  the  warty  cancer  the  papillae  are  them- 
selves cancerous  :  more  or  less  of  their  natural  shape,  or  of  the  manner 
of  their  increase,  may  be  traced ;  but  their  natural  structures  are  re- 
placed by  cancer  structures ;  the  cells  like  those  of  epithelium  lie  not 
only  over,  but  within,  them.f 

*  The  cauliflower  excrescence  of  the  uterus  may  be  most  nearly  compared  with  the  ex- 
tremely exuberant  epithelial  cancers  such  as  are  described  above  (see  p.  620). 

f  I  described  the  papillary  origin  and  construction  of  these  cancers  in  ]  838  (Medical  Ga- 
zette, xxiii,  284),  but  was  not  then  aware  of  their  minute  structure.  Later  examinations 
have  made  me  sure  that  the  true  distinction  between  them  and  other  papillary  growths  is 
as  above  stated.  But  it  is  to  be  observed  that  cancerous  growths  may  appear  papillary  or 
warty,  though  no  original  papillee  are  engaged  in  their  formation.  Thus  when  papillary 
cancers  are  deeply  ulcerated  at  their  centres,  the  base  of  the  ulcer,  where  all  the  original 
papillce  are  destroyed,  may  be  warty,  like  its  borders  where  the  cancerous  papiHse  are  evi- 
dent. Some  of  the  most  warty-looking  epithelial  cancers  are  those  which  grow  from  the 
deep  tissues  of  the  leg  after  old  injuries.  This  may  be  only  an  example  of  cancerous 
growths  imitating  the  construction  of  adjacent  parts;  but  in  some  instances  (as  in  cysts,  and 
on  the  mucous  membrane  of  the  gall-bladder  and  stomach),  the  warty  cancers  are  probably 
examples  of  the  dendritic  mode  of  growth.     It  must  also  be  a  question,  at  present,  whether 

.S9 


602  EPITHELIAL     CANCER. 

To  describe  the  interior  structure  of  the  superficial  cancerous  growths, 
we  may  take  as  types  the  most  common  examples  of  cancers  of  the 
lower  lip, — those  in  which  the  papillae  are  indeed  involved,  enlarged, 
and  cancerous,  but  not  so  as  to  form  distinct  or  very  prominent  out- 
growths. 

The  surface  of  a  vertical  section  through  such  a  cancer  commonly 
presents,  at  its  upper  border,  either  a  crust  or  scab,  formed  of  ichor, 
detached  scales,  and  blood ;  or  else  a  layer  of  detached  epidermoid 
scales,  forming  a  white,  crumbling,  pasty  substance.  This  layer  may 
be  imperceptible,  or  extremely  thin ;  but  it  may  be  a  line  or  more  in 
thickness ;  and  it  enters  all  the  inequalities  of  the  surface  on  which  it 
lies.  Its  cells  or  scales  are  not  regularly  tessellated  or  imbricated, 
like  those  of  the  epidermis  on  a  common  wart,  but  are  placed  without 
order,  loosely  connected  both  with  one  another  and  with  the  subjacent 
vascular  structures,  and  may  be  easily  washed  away. 

Such  a  layer  must  be  regarded,  I  presume,  as  formed  of  epithelial 
cancer-cells,  detached  or  desquamated  from  the  subjacent  vascular  and 
more  perfectly  organized  substance  of  the  cancer.  This  substance  pre- 
sents, in  most  cases,  or  in  most  parts,  a  grayish  or  grayish-white  color, 
and  shines  without  being  translucent.  It  is  firm  and  resilient,  close- 
textured,  and  usually  void  of  any  appearance  of  regularly  lobed,  granu- 
lar, or  fibrous  construction,  except  such  as  may  exist  near  its  surface, 
where  close-set  and  uniformly  elongated  vertical  papillae  may  make  it 
look  striped.  The  grayness  and  firmness  are,  I  think,  the  more  uniform 
and  decided  the  slower  the  growth  of  the  cancer  has  been.  In  the  acute 
cases,  especially  of  secondary  formations,  or  when  the  cancer  has  been 
inflamed,  or  ulceration  is  in  quick  progress,  the  cut  surface  may  be 
opaque-white,  or  of  some  dull  yellow  or  ochre  tint,  streaked  and 
blotched  with  blood ;  or  it  may,  in  similar  cases,  be  soft  and  shreddy, 
or  nearly  brain-like ;   but  these  appearances  are  very  rare. 

The  gray  substance  of  epithelial  cancers  commonly  yields  to  pressure 
only  a  small  quantity  of  turbid  yellowish  or  grayish  fluid  :  but  with 
rare  exceptions,  one  may  squeeze  or  scrape  from  certain  parts  of  the 
cut  surface,  as  if  from  small  cavities  or  canals,  a  peculiar  opaque-white 
or  yellowish  material.  It  is  like  the  comedones,  or  accumulated  epithe- 
lial and  sebaceous  contents  of  hair  follicles ;  or  even  more  like  what 
one  may  scrape  from  the  epidermis  of  the  palm  or  sole  after  long  mace- 
ration or  putrefaction.  This  material,  which  is  composed  of  structures 
essentially  similar  to  those  of  the  firmer  substance  of  the  cancer,  but 
difi"erently  aggregated,  supplies  one  of  the  best  characteristics  of  the 
disease.,.  It  may  be  thickly  liquid,  but  more  often  is  like  a  soft,  half- 
dry,  crumbling,  curdy  substance  :  pressed  on  a  smooth  surface,  it  does 
not  become  pulpy  or  creamy,  but  smears  the  surface,  as  if  it  were 

some  of  the  most  exuberant  cancers  of  the  skin  are  not  to  be  ascribed  to  this  mode  of 
growth.  It  is,  to  say  the  least,  extremely  difficult  to  trace  their  origin  from  once-natural 
papillae. 


INTERNAL    STRUCTURE.  603 

greasy  :  mixed  with  water,  it  does  not  at  once  diffuse  itself,  so  as  to 
make  the  water  uniformly  turbid,  but  divides  into  minute  visible  parti- 
cles.* 

The  quantity  of  this  softer  material  is  extremely  various  in  different 
instances  of  epithelial  cancer.  According  to  its  abundance  and  ar- 
rangement, the  gray  basis-substance  may  appear  differently  variegated ; 
and  the  more  abundant  it  is,  the  more  does  the  cancer  lose  firmness, 
and  acquire  a  soft,  friable,  and  crumbling  texture.  In  many  cases  the 
soft  substance  appears,  on  the  cut  surface,  like  imbedded  scattered  dots, 
or  small  grains :  these  being  sections  of  portions  contained  in  small 
cavities.  But,  as  the  quantity  increases,  and  the  cavities  containing  it 
augment  and  coalesce,  so  the  firmer  substance  becomes,  as  it  were,  cri- 
briform ;  or  when  the  softer  substance  is  washed  away,  it  may  appear 
reticulated  or  sponge-like,  or  as  if  it  had  a  radiated  or  plaited  struc- 
ture. Or,  lastly,  the  soft  substance  may  alone  compose  the  whole  of 
the  cancer :  but  this,  I  think,  is  very  rarely  the  case,  except  in  second- 
ary formations  and  in  the  lymphatic  glands. 

Vertical  sections  of  the  more  exuberant  and  the  more  distinctly  pa- 
pillary epithelial  cancers  present  essentially  the  same  appearance  as  I 
have  just  described.  The  upper  border,  corresponding  with  the  exposed 
part  of  the  growth,  may  be  overlaid  with  thin  scab,  or  crust,  or  epider- 
moid scales,  detached  and  disorderly,  or  may  be  bare,  like  that  of  a 
section  of  common  granulations.  The  cut  surface  is  generally  gray, 
succulent,  and  shining,  with  distinct  appearances  of  vascularity.  Por- 
tions of  it  may  yield  the  peculiar  soft  crumbling  substance  like  mace- 
rated epidermis  ;  but  this  is,  I  think,  generally  less  abundant  than  in 
the  less  exuberant  and  deeper  set  specimens,  and  is  more  often  arranged 
in  a  radiated  or  plaited  manner. 

The  vertical  sections  of  the  superficial  epithelial  cancers  of  the  in- 
teguments display  many  important  differences,  in  relation  to  the  depth 
to  which  the  cancer-structures  occupy  the  proper  tissues  of  the  skin  or 
mucous  membrane. 

In  some,  only  the  papillse,  or  the  papillae  and  the  very  surface  of  the 
tissue  on  which  they  rest,  appear  to  be  involved.  The  enlarged  papillse 
in  such  cases  usually  retaining  their  direction  and  their  cylindrical  or 
slenderly  conical  shape,  appear  like  fine  gray  stripes  or  processes  ver- 
tically raised  on  the  healthy  white  tissue  of  the  integument,  or  on  its 
surface  rendered  similarly  gray  by  cancerous  infiltration.  And  the  out- 
lines of  the  papillse  are  commonly  the  more  marked  because  of  their  con- 
trast with  the  opaque-white  substance  formed  by  the  epidermoid  scales 
which  cover  them  and  fill  up  all  the  interstices  between  them.    In  such 

*  In  these  are  its  distinctions  from  the  "juice"  of  either  scirrhous  or  medullary  cancers. 
But  it  must  be  remembered  that,  in  the  rare  instances  in  which  epithelial  cancers  are  very 
soft,  they  may  yield  a  creamy  or  turbid  grayish  fluid.  It  can  hardly  be  necessary  to  give  a 
caution  against  confounding  the  peculiar  material  described  above  with  that  which  may  be 
pressed  from  milk-ducts  involved  in  scirrhous  cancers  (compare  p.  528). 


604  SUPERFICIAL    EPITHELIAL     CANCER. 

cases  the  cancerous  material  may  be  more  abundant  on  the  surface  than 
in  the  substance  of  the  papillae  or  corium ;  and  often  the  whole  morbid 
substance  is  brittle,  and  may  be  separated  from  the  corium  which  bears 
the  papillee. 

But  more  frequently,  and  almost  always  in  such  cases  of  epithelial 
cancers  when  they  are  removed  in  operations,  the  cancerous  structures 
are  more  deeply  set.  They  occupy  the  whole  thickness  of  the  integu- 
ment, or  reach  to  a  level  deeper  than  it.  The  base  or  low^er  border  of 
the  diseased  mass  rests  on,  or  is  mingled  with,  the  subcutaneous  or  sub- 
mucous tissues,  whatever  these  may  be, — fat,  muscular  fibres,  or  any 
other.  The  lateral  borders  usually  extend  outwards  for  some  distance, 
on  each  side,  beneath  the  healthy  integument  which  bounds  the  upraised 
part  of  the  diseased  growth,  and  which  is  usually  raised  and  everted  so 
as  to  overhang  the  adjacent  surface.  In  nearly  all  these,  also,  while 
the  surface  and  central  parts  of  the  cancer  are  being  destroyed  by 
ulceration,  its  base  and  borders  are,  at  a  greater  rate,  extending  more 
deeply  and  widely  in  the  subcutaneous  or  submucous  tissues. 

The  bases  of  the  most  exuberant  and  most  distinctly  papillary  can- 
cers are  rarely,  in  the  early  periods  of  their  growth,  either  deeply  or 
widely  set  in  the  integument.  They  rarely,  I  believe,  occupy  more 
than  the  thickness  of  the  portion  of  the  skin  or  mucous  membrane  from 
which  the  growths  spring  :  they  sometimes  occupy  less.  But,  in  their 
later  growth,  and  especially  when  ulceration  is  progessive,  the  same 
deeper  and  wider  extension  of  the  base  of  the  cancer  ensues  as  I  men- 
tioned in  the  last  paragraph. 

All  the  foregoing  description  will  have  implied  that  the  proper 
structures  of  the  diseased  parts  are  mixed  up  with  the  cancer-structures 
inserted  among  them :  the  condition  of  parts  is  here  exactly  comparable 
with  that  of  other  cancerous  infiltrations.  (Compare  p.  523.)  The 
boundaries  of  the  cancer,  as  seen  in  sections,  usually  appear  to  the 
naked  eye  well-defined ;  yet  it  is  often  easy  to  see  portions  of  the 
natural  tissues  extending  into  it,  these  being  continuous  wath  those 
portions  among  which  the  cancer-structures  are  infiltrated.  This  is 
especially  evident  when,  as  in  the  lip  or  tongue,  the  superficial  muscular 
fibres  are  involved.  Pale  red  bands  may  then  be  traced  into  or  within 
the  cancer ;  and  the  microscope  will  prove,  if  need  be,  their  muscular 
structure.  Or,  when  these  cannot  be  traced,  yet  we  may  find  the  con- 
nective tissue  of  the  involved  skin  or  mucous  membrane. 

Concerning  the  changes  that  ensue  in  the  tissues  thus  involved  in  the 
deeper  parts  of  epithelial  cancers,  I  believe  that  what  was  said  of  those 
in  cancerous  breasts  (p.  523  and  529)  might  be  here  nearly  repeated, 
regard  being  had  to  the  original  difi'erences  of  the  tissues  in  the  respec- 
tive cases.  In  general,  the  natural  structures  in  these  cases  appear  not 
to  grow ;  gradually,  but  not  all  at  the  same  rate,  they  degenerate  and 
are  removed,  till  their  place  is  completely  occupied  by  the  increasing 
cancer-structures,  and  an  entire  substitution  is  accomplished.     So,  too, 


DEEP-SEATED     EPITHELIAL    CANCER.  605 

what  was  said  of  the  stroma  of  scirrhous  cancers  of  the  breast  might  be 
repeated.  These  epithelial  cancers  have  no  stroma  of  their  own  ;  their 
proper  structures  are  sustained  by  the  remains  of  the  original  textures 
of  the  aifected  part.  And,  as  in  the  scirrhous  cancers,  so  in  these; 
when  they  grow  very  quickly,  they  occupy  a  comparatively  small  area 
of  the  original  tissues,  and  may  appear  like  nearly  distinct  tumors. 

In  the  most  exuberant  epithelial  cancers,  and  in  those  that  are  pro- 
minent, like  warts  or  condylomata,  there  is  more  growth  of  the  natural 
tissues ;  those,  not  of  the  papillae  alone,  but  of  the  basis  of  the  skin  or 
mucous  membrane,  may  be  traced  into  the  outgrowth,  forming  a  stroma 
for  the  cancer-structures,  and  surmounted  by  the  cancerous  papillae. 
Such  a  stroma  may  be  well  traced  in  many  soot-cancer  warts:  the  con- 
nective tissue  extends  from  the  level  of  the  cutis,  in  vertical  or  radiating 
and  connected  processes  among  which  the  cancer-cells  lie;  and  one  may 
compare  them  with  the  osseous  outgrowths  that  form  an  internal  skele- 
ton of  a  cancer  on  a  bone  (see  p.  566). 

The  tissues  bordering  on  the  superficial  epithelial  cancers  appear 
generally  healthy,  but  they  are  often  increased  in  vascularity,  and 
succulent.  The  adjacent  corium  also  may  appear  thickened,  with  its 
papillae  enlarged,  and  an  unusual  quantity  of  moist  opaque-white  cuticle 
may  cover  them.*  This  condition  is,  however,  not  frequent;  neither  is 
it  peculiar  to  the  environs  of  cancer ;  changes  essentially  similar  are 
often  observed  around  chronic  simple  ulcers  of  the  integuments. f 

The  deep-seated  epithelial  cancers  remain  to  be  described.  In  the 
progress  of  all  the  preceding  varieties  of  the  superficial  form  of  the 
disease,  especially  when  their  surfaces  are  ulcerating,  we  may  trace  a 
constant  subintegumental  extension  of  their  bases,  in  both  width  and 
depth ;  an  extension  which  is  more  than  commensurate  with  the  de- 
struction at  the  surface,  and  in  the  course  of  which  no  tissue  is  spared. 
Now,  the  same  cancerous  infiltration  of  the  subcutaneous  or  submucous 
tissues,  which  is  thus  the  common  result  of  the  extension  of  the  disease 
from  the  surface,  may  also  occur  primarily :  that  is,  the  first  formation 
of  epithelial  cancers  may  be  in  masses  of  circumscribed  infiltration  of 
the  tissues  beneath  healthy  skin  or  mucous  membrane.  The  same 
condition  is  more  frequent  in  the  epithelial  cancers  that  form,  as  re- 
currences of  the  disease,  near  the  seats  of  former  operations,  or,  as 
secondary  deposits,  about  the  borders  of  primary  superficial  growths. 

In  comparison  with   the  superficial  form,  the  primary  deep-seated 

*  M.  Lebert  (Traite  Pratique,  p.  618)  quotes  from  M.  Follin,  that  the  tissues  around  the 
disease  are  often  "infiltrated  with  epidermis  in  a  diffuse  manner." 

f  On  some  of  the  diseases  of  the  papillae  of  the  cutis  (Medical  Gazette,  vol.  xxiii,  p.  2S5). 
The  multiform  appearances  of  epithelial  cancers  which  I  have  described  may  be  still  more 
varied  by  the  consequences  of  degeneration  and  disease.  But  it  would  be  too  tedious  to 
describe  them  minutely,  while,  as  I  believe,  they  are  essentially  similar  to  the  consequences 
of  the  same  affections  in  the  scirrhous  and  medullary  cancers,  of  which  I  have  already  given 
some  account. 


606  GENERAL     CHARACTERS. 

epithelial  cancer  is  a  very  rare  disease ;  yet  it  is  frequent  enough  for 
me  to  have  seen,  within  the  same  year,  three  cases,  which  I  will  de- 
scribe ;  for  they  were  all  well-marked  examples. 

A  chimney-sweep,  32  years  old,  died  suddenly,  suflFocated,  in  the 
night  after  his  admission  into  St.  Bartholomew's. 

He  had  had  cough  for  six  months,  and  aphonia  and  dyspnoea  for  two 
months.  A  scrotal  soot-cancer  had  been  removed  from  his  brother  in 
the  previous  year. 

I  found  a  wide-spread  layer  of  firm  substance,  exactly  like  that  of 
the  majority  of  epithelial  cancers,  under  the  mucous  membrane  of  the 
larynx,  involving  the  left  border  of  the  epiglottis,  the  left  arytenoid 
cartilage,  the  intervening  aryteno-epiglottidean  fold,  part  of  the  right 
arytenoid  cartilage,  and  the  upper  and  posterior  third  of  the  left  ala  of 
the  thyroid  cartilage.  In  all  this  extent,  the  diseased  substance  lay 
beneath  the  mucous  membrane,  which,  though  very  thinly  stretched 
over  some  parts  of  it,  appeared  healthy,  was  covered  with  ciliated  epi- 
thelium wherever  I  examined  it,  and  could  everywhere  be  separated  in 
a  distinct  layer.*  All  the  submucous  tissues  were  involved;  the  carti- 
lages, as  it  were  buried  in  the  growth,  appeared  less  changed  than  the 
softer  parts.  The  surface  of  the  growth,  as  covered  with  the  mucous 
membrane,  was  lowly  lobed,  or  tuberculated,  raised  from  one  to  two 
lines  above  the  natural  level ;  its  border  was  in  many  parts  sinuous. 
The  cancerous  substance  was  firm,  elastic,  compact,  grayish  and  white, 
shining,  variously  marked  on  its  section  with  opaque-white  lines.  It 
appeared  wholly  composed  of  the  usual  minute  structures  of  epithelial 
cancers,  including  abundant  laminated  epithelial  capsules.  All  the 
epithelial  structures  were  of  the  scale-like  form,  though  collected  in  the 
tissues  under  a  membrane  covered  with  ciliated  epithelium. 

A  man  was  admitted  into  the  hospital,  in  a  dying  state,  with  a  large 
firm  swelling  between  the  lower  jaw  and  the  hyoid  bone,  the  increase  of 
which  had  produced  great  difficulty  of  breathing  and  swallowing.  After 
his  death,  the  greater  part  of  the  swelling  was  found  to  be  due  to  cancer 
of  the  deep  tissues  of  the  tongue,  and  of  the  fauces  and  lymphatic  glands. 
A  section  of  the  parts  (as  in  Fig.  100)  showed  that  the  muscular  and 
other  structures  of  the  posterior  two-thirds  of  the  tongue  were  completely 
occupied  by  a  firm  cancerous  infiltration:  but  th^  mucous  membrane  of 
the  tongue  was  entire ;  its  various  papillary  structures  were  healthy  and 
distinct ;  it  was  only  tight-stretched  and  adherent  on  the  surface  of  the 
cancer.  From  the  base  of  the  tongue  the  cancer  extended  backwards 
and  downwards  on  both  sides  of  the  fauces,  and  as  far  as  the  vocal  cords, 
preserving  in  its  whole  extent  the  characters  of  a  massive  infiltration  of 
all  the  submucous  tissues.  It  was  covered  with  healthy-looking  mucous 
membrane  in  every  part,  except  just  above  the  right  vocal  cord,  where 

*  The  specimen,  and  those  referred  to  in  the  two  following  cases,  are  in  the  Museum  of 
St.  Bartholomew's. 


EPITHELIAL    CANCER ULCERATION. 


607 


Fig.  100. 


it  protruded  slightly  through  a  circular  ulcer  less  than  half  an  inch  in 
diameter.     The  substance  of  the  disease  presented,  to  the  assisted  as 
well  as  to  the  unaided  sight,  and  touch,  the 
well-marked  characters  of  epithelial  cancers. 
The  lymphatic  glands  were  similarly  diseased. 

A  gentleman,  64  years  old,  had,  on  the 
upper  part  and  right  side  of  his  nose,  a  flat, 
lowly  lobed  or  tuberculated  growth,  an  inch  in 
diameter,  gradually  rising  above  the  level  of 
the  adjacent  skin  to  a  height  of  one  and  a  half 
or  two  lines.  It  was  covered  with  skin,  which 
was  very  thin  and  adherent,  and  florid  with 
small  dilated  bloodvessels,  like  those  in  the 
skin  of  his  cheek.  The  base  of  the  growth 
rested  on  the  bones  ;  it  felt  like  an  infiltration 
of  all  the  thickness  of  the  deeper  part  of  the 
skin  and  subcutaneous  tissues,  and  moved  as 
.one  broad  and  thick  layer  of  morbid  substance 
inserted  in  the  skin.  In  its  middle  and  most 
prominent  part  was  a  fissure  nearly  a  line  in 
depth,  with  black,  dry  borders,  from  which  a 
very  slight  discharge  issued.  It  was  very 
painful,  and  beginning  from  no  evident  cause, 
had  been  ten  weeks  in  regular  progress. 

I  removed  this  disease,  and  found  in  its 
centre  a  small,  roundish  mass  of  soft,  dark, 
grumous  substance,  like  the  contents  of  a 
sebaceous  cyst.*    Around  the  cavity  in  which 

this  was  contained,  all  the  rest  of  the  disease  appeared  as  an  outspread 
infiltration  of  firm  yellowish  and  white  cancerous  substance  in  the  tissues 
under  the  stretched  and  adherent  but  entire  skin.  It  extended  as  deep 
as  the  periosteum  of  the  nasal  bones.  Soft,  crumbling,  and  grumous 
substance  could  be  scraped  from  it ;  and  it  yielded  well-marked  elements 
of  epithelial  cancer,  with  numerous  laminated  capsules.  During  the 
healing  of  the  operation  wound,  a  similar  small  growth  appeared  in  the 
adjacent  tissues.  It  was  destroyed  with  caustic  by  Mr.  Hester,  and 
the  patient  has  remained  well  ten  years  since  the  operation. 

Besides  cases  such  as  these,  which  may  suffice  for  a  general  descrip- 
tion of  the  disease,  many  might  be  cited  of  what  may  be  regarded  as  an 
intermediate  form,  in  which  both  the  skin  or  mucous  membrane  and  the 
subjacent  tissues  are  simultaneously  afi"ected,  but  the  latter  to  a  much 
larger  extent  than  the  former.  Such  cases  are  far  from  rare  in  the 
lower  lip  and  tongue.     They  are  characterized  by  the  existence  of  a 


*  Mr.  Hester  and  Mr.  Rye,  who  saw  this  case  some  weeks  before  I  did,  told  me  that  it 
presented,  at  first,  all  the  characters  of  a  common  sebaceous  cyst ;  and  I  think  it  quite  pro- 
bable that  it  w^as  an  example  of  epithelial  cancer  formed  in  and  around  such  a  cyst. 


608  EPITHELIAL    CANCER. 

roundish,  firm,  or  hard  and  elastic  lump,  deep-set  in  the  part,  and  well 
defined  to  the  touch,  with  its  surface  little,  if  at  all,  raised,  and  having 
at  some  part  of  its  surface  either  a  portion  of  cancerous  integument,  or 
a  small  ulcer  or  fissure. 

Now  these  cases  of  deep-seated  epithelial  cancers  have  much  interest, 
as  well  in  practice  as  in  their  bearing  on  the  pathology  of  the  disease. 
Thej  are  instances  of  the  disease  of  which  it  is  impossible  to  speak  as 
of  mere  augmentations  of  the  natural  structures ;  there  is  in  them  no 
trace  at  all  of  the  assumed  homology  of  epithelial  growths ;  there  is  in 
them  no  progressive  formation  of  epithelial  cells  gradually  penetrating 
from  the  surface  into  the  substance  of  the  cutis ;  their  progress,  or  a 
part  of  it,  is  from  the  deeper  parts  towards  the  surface. 

The  epithelial  cancers  in  or  near  the  integuments  are  so  prone  to 
ulceration,  that  the  occasions  of  seeing  them  as  mere  growths  are  com- 
paratively rare.  The  state  in  which  they  are  usually  shown  to  us  is 
that  of  progressive  ulceration  of  the  central  and  superficial  parts,  with 
more  than  equal  growth  of  thq  bordering  and  deeper  parts.  In  this 
state,  indeed,  they  present  the  type  of  that  which  is  commonly  described 
as  the  cancerous  ulcer,  a  type  which  is  observed,  also,  in  some  examples 
of  the  scirrhous  cancer  (p.  549),  and  more  rarely  in  the  medullary. 

In  the  superficial  first-described  form  of  the  disease,  the  ulceration 
usually  begins  either  as  a  diffused  excoriation  of  the  surface  of  the 
cancer,  the  borders  of  which  are  alone  left  entire,  or  else  as  a  shallow 
ulcer  extending  from  some  fissure  or  loss  of  substance  at  which  the 
disease  commenced.  The  discharge  from  the  excoriated  or  ulcerated 
surface  usually  concretes  into  a  scab,  or  a  thicker  dark  crust,  beneath 
which,  as  well  as  beyond  its  edges,  ulceration  gradually  extends  in 
width  and  depth. 

A  nearly  similar  method  is  observed,  I  believe,  in  the  earliest  ulcera- 
tion of  the  papillary  and  other  more  exuberant  epithelial  cancers. 
The  central  parts  ulcerate  first,  and  the  ulcer  from  this  beginning 
deepens  and  widens,  destroying  more  and  more  of  the  cancer-structures; 
but  its  rate  of  destruction  is  never  so  quick  as  that  of  the  increase  of 
the  borders  and  base  of  the  cancer. 

In  the  deep-seated  epithelial  cancers,  other  methods  are  observed  in 
the  first  ulceration.  Sometimes  the  skin  or  mucous  membrane  over 
them,  becoming  adherent  and  very  thin,  cracks,  as  it  may  when  ad- 
herent over  a  scirrhous  cancer  (p.  548).  Such  a  crack  may  remain  long 
with  little  or  no  increase,  dry  and  dark,  and  scarcely  discharging ;  but 
it  is  usually  the  beginning  of  ulceration,  which  extends  into  the  mass 
of  the  cancer.  In  other  cases,  with  inflammation  of  the  cancer,  its 
central  parts  may  soften  and  perhaps  suppurate ;  and  then  its  liquid 
contents  being  discharged  (sometimes  with  sloughs),  through  an  ulce- 
rated opening,  or  a  long  fissure,  a  central  cavity  remains,  from  the 
uneven  walls  of  which  ulceration  may  extend  in  every  direction.  And 
again,  in  other  cases,  especially,  I  think,  in  secondary  formations,  and 


I 


ULCERATION.  609 

in  those  under  the  scars  of  old  injuries,  the  cancer  protrudes  through  a 
sharply  bounded  ulcer,  in  the  sound  integument  or  scar,  and  groAvs 
exuberantly,  with  a  soft,  shreddy  surface,  like  a  medullary  cancer,  or 
with  a  firmer,  warty  or  fungous  mass  of  granulations. 

But  though  the  beginnings  of  the  ulcers  be  thus,  in  difi"erent  instances, 
various,  yet  in  their  progress  they  tend  to  uniformity.  The  complete 
ulcer  is  excavated  more  or  less  deeply,  and  usually  of  round,  or  oval, 
or  elongated  shape.  Its  base  and  borders  are  hard,  or  very  firm,  be- 
cause, as  one  may  see  in  a  section  through  it,  they  are  formed  by  can- 
cerous substance  infiltrated  in  the  tissues  bounding  it.  The  thickness 
of  this  infiltration  is  commonly,  in  direct  proportion  to  the  extent  of 
the  ulcer,  from  a  line  to  half  an  inch  or  more :  we  may  feel  it  as  a  dis- 
tinct and  well-defined  indurated  boundary  of  the  whole  ulcer,  hindering 
its  movement  on  the  deeper  tissues.  The  surface  of  the  base  of  the 
ulcer  is  usually  concave,  unequal,  coarsely  granulated,  nodular,  or 
warty :  it  is  florid,  or,  often,  of  a  dull  vermilion,  or  rusty  red  color ;  it 
bleeds  readily,  but  not  profusely  ;  and  yields  a  thin  ichorous  fluid,  which 
is  apt  to  form  scabs,  and  has  a  peculiarly  strong,  offensive  odor,  some- 
thing like  that  of  the  most  offensive  cutaneous  exhalations.  The  bor- 
ders of  the  ulcer,  or  some  parts  of  them,  are,  generally,  elevated,  sinu- 
ous, tuberous,  or  nodulated ;  frequently,  they  are  everted  and,  to  a 
less  extent,  undermined.  They  derive  these  characters,  chiefly,  from 
the  cancerous  formations  beneath  the  skin  or  mucous  membrane  that 
surrounds  the  ulcer.  These  formations  may  be  in  a  nearly  regular 
layer,  making  the  border  of  the  ulcer  like  a  smoothly  rounded  embank- 
ment ;  but  oftener,  though  continuous  all  around  the  ulcer,  they  are 
unequal  or  nodular,  and  then  corresponding  nodules  or  bosses,  from  a 
line  to  nearly  an  inch  high,  may  be  raised  up  around  the  ulcer,  or  some 
part  of  it.  Moreover,  these  upraised  borders  may  so  project  as  to  over- 
hang both  the  base  of  the  ulcer  and  the  adjacent  healthy  surface  of  the 
skin  or  mucous  membrane ;  they  thus  appear,  at  once,  undermined  and 
everted.  When  they  are  everted,  healthy  skin  is  usually  reflected 
under  them,  and  continued  beneath  them  to  their  extreme  boundary. 
When  the  papillary  character  of  the  primary  growth  was  well  marked, 
the  borders  of  the  ulcer  often  present,  instead  of  the  characters  just 
described,  a  corresponding  papillary  or  warty  structure  :  for,  in  these 
cases,  the  cancer  continues  apt  to  affect  especially  the  papillae,  and 
widening  areas  of  them  become  its  seat  as  it  extends.  And,  even  at 
the  base  of  the  very  deep  ulcers,  the  cancerous  granulations,  though 
rising  from  the  tissues  far  deeper  than  papillse,  may  have  a  similarly 
warty  construction. 

The  characters  of  the  ulcer  here  described,  are  generally  retained, 
however  deep,  and  into  whatever  tissues,  the  cancer  may  extend.  For 
the  proper  tissues  of  the  successively  invaded  parts,  at  first  infiltrated 
with  cancer-structures,  seem  to  be  quickly  disparted  and  then  removed ; 
even  the  bones  rarely  produce  any  outgrowths  corresponding  with  those 


610  EPITHELIAL     CANCEE. 

that  are  found  in  medullary  cancers  ;  they  become  soft,  are  broken  up, 
and  at  length  utterly  destroyed.  Epithelial  cancers  thus  extending  pro- 
duce the  changes  described,  as  characteristic  of  malignant  ulceration, 
in  p.  346  ;  and  by  similar  extension  (especially  in  the  aifections  of  the 
lymphatic  glands),  they  lay  open  great  bloodvessels  more  often  than 
any  other  ulcers  do.  I  have  seen  three  cases  in  which  the  femoral  artery 
was  thus  opened  by  ulceration  extending  from  the  epithelial-cancerous 
inguinal  glands. 

The  minute  component  structures  of  the  epithelial  cancers  are  alike 
among  all  the  varieties  of  construction  and  external  shape  that  I  have 
now  described  ;  and,  if  we  omit  the  proper  textures  of  the  part  affected, 
they  may  be  thus  enumerated :  (a)  epithelial  cancer-cells ;  (b)  nuclei, 
either  free,  or  imbedded  in  blastema  ;  (c)  endogenous  or  brood-cells  ;  (d) 
laminated  epithelial  capsules,  or  epithelial  globes.  From  each  of  these, 
by  degeneration  or  other  change,  several  apparently  different  forms 
may  be  derived.  The  proportions,  also,  in  which  they  are  combined 
are  various  in  different  specimens ;  but  I  believe  that  diversities  of  ap- 
pearances to  the  naked  eye  are  not  so  connected  with  these  proportions, 
as  with  the  methods  of  arrangement,  the  degrees  of  degeneration  of  the 
component  structures,  and  the  mingling  of  the  products  of  inflammation 
in  the  cancer. 

(a)  The  most  frequent  cells  (Fig.  101,  a),  and  those  which  may  be 
regarded  as  types,  are  nucleated,  flattened,  thin  and  scale-like.  They 
are,  generally,  round  or  round-oval ;  but  they  seldom  have  a  regular 
shape:  their  outline  is,  usually,  at  some  part,  linear,  or  angular,  or 
extended  in  a  process.  Their  average  chief  diameter  is  about  T^sth  of 
an  inch ;  but  they  range  from  -zosth.  to  ^to oth,  or  perhaps  beyond  these 
limits.  In  the  clear,  or  very  palely  nebulous,  cell-contents,  a  few 
minute  granules  usually  appear,  either  uniformly  scattered,  or  clus- 
tered, as  in  an  areola,  around  the  nucleus. 

The  nucleus  is  usually  single,  central,  and  very  small  in  comparison 
with  the  cell,  rarely  measuring  more  than  ^sVoth  of  an  inch  in  its  longest 
diameter  :  it  is  round  or  oval,  well  defined,  and  subject  to  no  such  varie- 
ties of  shape  and  size  as  the  cell.  It  is  usually  clear  and  bright,  and  is 
often  surrounded  by  a  narrow,  clear  area ;  it  may  contain  two  or  more 
minute  granules,  but  rarely  has  a  bright,  distinct  nucleolus. 

But  many  of  the  cells  may  deviate  widely  from  these  characters;  the 
most  various  and  (if  the  term  may  be  used)  fantastic  shapes  may  be 
found  mingled  together.  The  younger  cells  are  generally  smaller, 
rounder,  more  regular,  less  flattened  to  the  scale-like  form,  clearer,  and 
with  comparatively  large  nuclei.  The  older  (as  I  suppose)  appear  drier 
and  more  filmy  ;  they  are  often  void  of  nuclei,  and  like  bits  of  membrane 
in  the  shape  of  epithelial  scales  (b)  :  they  are  flimsy,  too,  so  that  they 
are  very  often  wrinkled  or  folded  and  rolled  up,  so  as  to  look  fibrous 
(c),  and  not  unlike  the  elongated  epithelium  scales  so  often  seen  on  the 


MINUTE    STRUCTURES. 


611 


dorsum  of  the  tongue.     Independently  of  differences  of  age,  some  cells 
are  prolonged  in  one,  two,  or  more  slender  or  branching  processes ; 

Fig.  101.* 


some  are  very  elongated  (as  d);  some  are  void  of  nuclei;  some,  within 
their  pale  borders,  present  one  or  two  dimly  marked  concentric  rings, 
as  if  they  had  laminated  walls. 

To  these  varieties  may  be  added  such  as  depend  on  the  progressive 
degeneration  of  the  cells.  The  most  frequent  (besides  the  withering, 
which,  I  suppose,  is  shown  in  the  shrivelled  flimsy  scales  without  nuclei 
just  mentioned)  is  the  change  like  fatty  degeneration  in  other  cancer- 
structures.  One  of  the  most  frequent  efforts  of  such  degeneration  is 
that  the  place  of  the  nucleus  is  occupied  by  a  circular  or  oval  group  of 
minute  oily-looking  molecules,  some  bright  with  black  borders,  some 
dark  (Fig.  102).     Others,  like  these,  or  larger,  are  generally  scattered 

Fig.  I02.t 


through  the  cell.  With  the  progress  of  the  degeneration,  all  trace  of 
the  nucleus  is  lost ;  the  molecules  increase  in  number  and  in  size,  till 
the  whole  cell  or  scale  appears  filled  with  them,  or  is  transformed  into 
an  irregular  mass  of  oily-looking  particles,  differing  in  shape  alone  from 
the  common  granule  masses  of  fatty  degenerations. 

(b)  Nuclei,  either  free  or  imbedded  in  a  dimly  molecular  or  granular 
basis,  are  commonly  found  mingled  with  the  cells.  I  believe  they  oc- 
cur in  the  greatest  abundance  in  the  most  acute  cases.  They  may  be 
just  like  the  nuclei  of  the  cells ;  but,  usually,  among  those  that  are  free, 
many  are  larger  than  those  in  the  cells  ;  and  these,  reaching  a  diameter 
of  more  than  g^^^jth.  of  an  inch,  at  the  same  time  that  they  appear 
more  vesicular  and  have  larger  and  brighter  nucleoli,  approximate  very 
closely  to  the  characters  of  the  nuclei  of  scirrhous  and  medullary  can- 
cer-cells.    Indeed,  I  have  seen  many  nuclei  in  soot-cancers,  which,  if 

*  Various  epithelial  cancer-cells  or  scales.     Magnified  350  times  :  referred  to  in  the  text. 
f  Cells  and   free  nuclei  of  epithelial  cancer,  in  states  of  fatty  degeneration.     Magnified 
350  times. 


612 


EPITHELIAL    CANCER. 


tliey  had  been  alone,  I  could  not  have  distinguished  from  such  as  are 
described  at  page  527  :  yet  all  the  other  structures  of  these  specimens 
were  those  usual  in  epithelial  cancers,  and  between  the  different  charac- 
ters of  nuclei  there  were  all  possible  gradations.  The  free  nuclei,  like 
the  cells,  may  be  found  in  all  stages  of  degeneration  (Fig.  102). 

(e)  Those  which  are  named  brood-cells,  or  endogenous  cells,  present 
many  varieties  of  appearance,  which  may  be  regarded  as  the  results  of 
one  or  more  nuclei,  inclosed  within  cells,  assuming,  or  tending  to  as- 
sume, the  characters  of  nucleated  cells  (Fig.  103).*  In  some  cells  a 
nucleus  appears  very  large,  clear,  pellucid,  spherical :  it  loses,  at  the 
same  time,  its  sharply  defined  outline,  its  boundary  becomes  shadowed, 
and  it  looks  like  a  hole  or  vacant  space  in  the  cell  (a).  Thus  enlarging, 
the  nucleus  may  nearly  fill  the  cell,  and  appear  as  a  pellucid  vesicle. 
I  think,  however,  that  such  nuclei  rarely  grow  to  be  cysts,  like  those 
whose  history  is  described  in  Lecture  XXII ;  for  cysts  containing 
serous  or  other  fluids  are  very  rarely  found  in  epithelial  cancers. 
Neither  have  I  seen  instances  pf  free  nuclei  changed,  as  those  in  the 
cells  are.f 

The  enlarged  nucleus  may  remain  completely  pellucid  or  barren  ; 
but  often  granular  matter  appears  to  fill  it ;  and,  as  often,  one  or  two 
corpuscles  form  in  it,  which  now  appear  as  its  nuclei,  and  make  it  as- 
sume the  character  of  a  cell,  endogenous  within  the  first  or  parent-cell 
(b).  The  sketches  show  many  of  the  appearances  that  may  be  hence 
derived  ;  and  others  may  be  thus  explained.     When  a  cell  contains  two 

Fig.  1034 


nuclei,  one  only  of  these  may  enlarge  or  become  inflated  (if  I  may  use 
such  a  term  for  that  which  fills  with  liquid,  not  with  air) ;  the  other 

*  We  owe  the  ability  to  interpret  these  appearances,  which  ilhistrate  many  things  inte- 
resting in  the  general  physiology  of  cells,  almost  entirely  to  Virchow  (in  his  Archiv,  iii,  197) 
and  Rokitansky,  1.  c.  Other  facts,  derived  from  the  examination  of  solid  tumors,  and  illus- 
trating the  capacity  of  the  nucleus  for  development,  are  in  pages  440,  572  :  all  these  may 
deserve  study  in  physiology,  together  with  the  doctrine  of  cyst-formation,  explained  at  p. 
.356,  &c.  The  vesicular  spaces  which  sometimes  form  not  only  in  cancer-cells,  as  described 
in  the  text,  but  in  the  cells  of  other  parts,  as  in  the  thymus,  Virchow  has  described  by  the 
name  of  physalides  (brood-cavities),  whilst  to  the  cells  in  which  these  spaces  arise,  he  has 
given  the  name  of  physaliphores. 

t  Virchow,  however  (Wiirzburg  Verhandl.,  i,  100),  mentions  having  found,  in  a  cauli- 
flower excrescence  of  the  uterus,  alveoli  which,  after  the  plan  of  proliferous  cysts,  contained 
secondary  papillary  growths.  The  analogy  of  other  proliferous  cysts  may  indicate  that  these 
also  originated  in  nuclei. 

J  Epithelial  cancer-cells,  with  endogenous  development  of  nuclei,  as  described  in  the 
text.     Magnified  350  times. 


MINUTE    STRUCTURES. 


613 


may  be  then  pressed  against  the  wall  of  the  cell.  Or  both  nuclei  may 
alike  proceed  to  the  grade  of  cells,  and  two  cells,  flattened  at  their 
place  of  mutual  compression,  appear  within  the  parent-cell  (c) :  or  a 
secondary  nucleus,  i.  e.,  one  formed  within  an  enlarged  nucleus,  may 
enlarge  like  its  predecessor,  and  become  like  a  pellucid  cavity,  or  may 
become  a  secondary  cell,  and  contain  its  tertiary  nucleus  :  hence,  pos- 
sibly, the  concentric  appearance  above-mentioned  may  be  referred  to 
the  series  of  successively  inclosed  cell-walls  (d).  And  changes  such  as 
these  may  equally  occur  with  more  than  two  nuclei :  a  cell  of  any  grade, 
primary,  secondary,  or  later,  may  be  filled  with  a  numerous  "  brood" 
of  nuclei,  in  which  all  the  above  described  changes  (but  not  the  same 
in  all)  may  be  repeated. 

(<:^)  The  laminated  capsules,  as  I  have  called  them  ("  globes  epider- 
miques"  of  Lebert),  are  the  most  singular  and  characteristic  structures 
of  the  epithelial  cancers  (Fig.  104).  They  are  not,  indeed,  peculiar 
to  this  disease  ;  for  I  have  found  exactly  corresponding  structures  in 
the  contents  of  an  epidermal  and  sebaceous  cyst ;  and  so  has  V.  Baren- 
sprung  ;*  and  I  have  illustrated  a  corresponding  mode  of  formation  in 
some  of  the  many-nucleated  cells  of  myeloid  tumors  (Fig.  73,  p.  469). 
However,  they  are,  I  believe,  nowhere  so  frequent,  or  so  well  marked, 
as  they  are  in  nearly  every  epithelial  cancer. 

Their  great  size  at  once  attracts  the  eye :  they  are  visible  even  to 
the  unaided  sight,  especially  Avhen  the  softer  curdy  material  of  the  can- 
cer, in  which  they  are  generally  most  abundant,  is  pressed  out  on  glass. 
They  appear  at  first  sight  like  spherical  or  oval  cysts,  from  x^o^h  to 
g^oth  of  an  inch  in  diameter,  walled  in  by  irregular  fibrous  tissue,  and 
containing  granular  matter,  nuclei,  or  cells,  obscurely  seen  within  them 
(Fig.  104,  c).  They  may  be  clustered  together  in  a  mass  or  a  long- 
Tig.  104.1 


cylinder  (d);  but  by  breaking  them  up,  or  looking  more  closely,  it  be- 
comes evident  that  the  appearance  of  fibrous  tissue  is  due  to  one's  seeing 

*  Vircbow  says  these  are  common  enough  in  all  accumulations  of  epidermis.  He  de- 
scribes them  in  morbid  thickenings  of  cuticle  under  the  nails,  in  his  Archiv,  B.  v,  H.  i,  p.  87, 
1  854.     See  also  Archiv,  iii,  200. 

f  Fig.  104.  Laminated  epithelial  capsules,  described  in  the  text.  Magnified  about  250 
times. 


614 


EPITHELIAL    CANCER. 


the  edges  of  epithelial  scales,  which,  in  successive  layers,  are  wrapped 
around  the  central  space.  Such  scales  may  be  broken  off,  in  groups  of 
two,  three,  or  more,  retaining  the  curved  form  in  which  they  have  lain 
(Fig.  104,  a).  When  detached,  they  generally  appear  like  the  dryest 
and  most  filmy  of  the  epithelial  scales  composing  the  rest  of  the  cancer 
(b)  :  often  they  are  folded,  and  look  fibrous  even  when  separated  ;  their 
nuclei  are  shrivelled  or  not  visible  ;  their  contents  are  often  granular. 
As  they  lie  superposed,  they  appear  closely  compacted  ;  but  not  un- 
frequently  granules  are  distinct  in  the  outer  laminar  spaces,  or  on  the 
inner  surface  of  detached  pieces. 

The  contents  filling  the  central  spaces  in  these  laminated  capsules 
are  extremely  various ;  sometimes,  or  partly,  granular  and  oily  parti- 
cles diffused  in  some  nebulous  material ;  more  often,  or  with  these,  cells 
or  nuclei  (c,  d).  Sometimes  one  cell  is  thus  inclosed,  sometimes  two 
or  more  :  and  these  not  scale-like,  but  oval,  or  round  and  plump,  having 
distinct  and  generally  large  nuclei ;  or  a  crowd  of  nuclei  may  be  in- 
closed :  and,  briefly,  these  nuclei  may  appear  in  any  of  those  various 
states  which  I  described  just  now  in  the  account  of  the  endogenous 
epithelial  cells.  Indeed,  it  is  probable  that  the  last  sentence  of  that 
description  (p.  613)  might  begin  the  history  of  the  development  of  these 
capsules ;  for  I  know  no  method  of  explaining  them,  except  that  taught 
by  Rokitansky,  and  illustrated  by  the  diagrams  copied  here  (Fig.  105).* 
In  one  of  the  simplest  cases,  we  may  suppose  a  nucleus  largely  in- 
flated and  filled  with  a  brood  of  (say  four)  secondary  nuclei,  which  pro- 
ceed to  the  formation  of  secondary  cells  (Fig.  105,  a).     If,  now,  only 

one  of  the  nuclei  of  these  secondary  cells 
becomes  enlarged,  it  will  not  only  extend 
its  own  cell's  wall  into  contact  with  that 
of  the  cell  containing  it,  but  will  at  the 
same  time  press  the  three  other  cells  into 
similar  contact,  and  thus  appear  invested 
with  laminated  epithelial  scales.  Such  a 
state,  with  the  nuclei  of  the  investing 
scales,  is  shown  in  b.  A  greater  com- 
plexity of  similar  events  is  shown  in  C,  in 
which,  among  a  very  large  number  of  se- 
condary endogenous  nuclei,  many  are  per- 
sistent as  nuclei,  while  others,  developed 
to  nucleated  cells,  are  laminated  around 
them.  But,  among  the  nuclei,  two  are 
represented  as  enlarged  and  containing 
tertiary  "broods"  of  nuclei,  among  which 


Fig.  105.  t 


*   From  his  essay,  Ueber  die  Cyste  :  Fig.  8. 

f  Fig.    105.     Diagrams  of  the  production   of  the   laminated   epithelial  capsules;   from 
Rokitansky. 


MINUTE    STRUCTURES.  615 

the  same  changes  have  ensued  as  in  the  preceding  generation.  And  it 
is  evident  that  if  any  in  the  group  a  had  noAV  singly  enlarged,  the  rest, 
with  all  the  cells  and  nuclei  around  them,  must  have  arranged  them- 
selves or  been  compressed  into  imbricated  scales,  so  as  to  form  a  large 
laminated  capsule. 

The  component  structures  now  described  appear  to  be  disorderly 
placed  in  the  mass  of  epithelial  cancer,  in  the  interstices  of  the  natural 
structures,  or  of  their  remains.  I  have  never  seen  any  of  them  within 
a  natural  structure,  e.  g.  within  a  muscular  fibre.*  The  laminated  cap- 
sules are,  I  believe,  most  abundant  in  the  softer  substance,  but  they 
are  not  confined  to  it.  The  texture  of  the  mass  is  such  as  makes  it 
very  difficult  to  obtain  a  sufficiently  thin  section  with  the  structures 
undisturbed ;  but  in  sections  of  scrotal  cancers  I  have  seen  the  lami- 
nated capsules  imbedded  at  distant  intervals  among  the  simpler  epithe- 
lial structures,  and  the  turgid  large  capillaries  ascending  tOAvards  the 
surface  and  forming  near  it  simple  or  undulating  loops.  The  epithelial 
structures  appear  to  be  in  contact  with  the  walls  of  the  bloodvessels, 
supported  by  a  wide  and  scanty  meshwork  of  connective  tissue  growing 
up  from  the  adjacent  tissue  of  the  scrotum. 

In  whatever  part  or  organ  they  may  be  found,  there  is  a  remarkable 
uniformity  in  the  characters  of  the  epithelial  cancer-structures.  De- 
viations, however,  from  such  as  I  have  described  as  the  normal  struc- 
tures are  sometimes  met  with.  I  have  once  seen  a  melanotic  epithelial 
cancer :  it  grew  in  the  deeper  part  of  the  cutis  and  in  the  subcutaneous 
tissue,  under  a  dark  pigmentary  nasvus  or  mole,  in  a  woman  who  had 
many  similar  moles  on  various  parts  of  her  body:  a  thin  layer  of  the 
cutis,  with  its  covering  of  dark  epidermis,  extended  over  the  cancer, 
and  was  slightly  raised  by  it.  The  epithelial  shape  and  texture  of  the 
cancer-cells  were  well-marked,  but  most  of  them  contained  melanotic 
matter  ;  in  some,  a  quantity  of  brownish  molecular  matter  was  either 
diffused  or  collected  about  the  nucleus  or  its  place  ;  in  some,  with  simi- 
lar molecular  matter,  there  were  two,  three,  or  more  brown  corpuscles, 
from  the  size  of  mere  molecules  to  that  of  blood-cells.  Materials  like 
those  within  the  epithelial  cells  existed,  also,  more  abundantly  as  an 
intercellular  substance. 

Cells  like  cylindriform  epithelium  cells  may  also  be  mingled  with 
the  more  usual  form.  I  have  seen  this  in  a  case  of  large  "  cauliflower- 
excrescence"  of  the  uterus,  in  the  very  substance  of  which  the  cylin- 
driform cells  were  found. 


*  C.  0.  Weber  in  Virchow's  Arcliiv,  vol.  xv,  1859,  has  described  and  figured  cases  ol 
epithelial  cancer  of  the  tongue  and  lip,  in  which  not  only  in  the  connective  tissue  between 
the  muscular  fibres,  but  apparently  within  the  fibres  themselves,  crowds  of  cells  possessing 
the  epithelial  character  were  situated.  These  had  evidently  arisen  through  division  and 
proliferation  of  the  original  cells  and  nuclei  of  the  textures  in  which  this  new  cell  formation 
had  taken  place. 


616       EPITHELIAL    CANCER    IN    THE    LYMPHATIC     GLANDS. 

Bidder  describes  a  similar  occurrence  in  a  cancer  of  the  stomach* 
and  duodenum ;  and  Rokitansky,t  ^^  ^^^  same  parts. | 

I  believe,  also,  that  cases  may  be  found  in  which  the  cancer-cells,  or 
part  of  them,  have  characters  intermediate,  or  transitional,  between 
those  of  the  epithelial  and  of  the  scirrhous  or  medullary  diseases.  I 
have  mentioned  the  existence  of  the  large  free  nuclei  (p.  611),  and  the 
full  plump  cells  in  the  capsules  (p.  614)  in  epithelial  cancers  ;  and  I 
believe  that  I  have  seen  cancers  with  all  their  cells  of  intermediate 
shape.  But  the  point  is  very  difficult  to  determine.  Young  epithelial 
cells  are  less  flattened  and  scale-like,  and  have  larger  and  clearer  nu- 
clei, than  those  of  completed  formation :  in  these  characters  they  ap- 
proach to  the  appearance  of  the  other  cancer-cells  ;  and  if,  in  a  quickly 
growing  mass,  they  occur  alone,  they  may  produce  a  fallacious  appear- 
ance of  an  intermediate  form  of  cancer.  Moreover,  two  kinds  of  can- 
cer may  be  mingled  in  one  mass.  Lebert  and  Hannover  have  satisfied 
themselves  of  this ;  and  such  a  specimen  as  they  describe  may  have  de- 
ceived me.  As  yet,  therefore,  I  can  have  only  a  belief  in  the  exis'tence 
of  such  intermediate  forms. 

The  foregoing  description  has  been  drawn,  almost  exclusively,  from 
cases  of  epithelial  cancer  in  integumental  parts,  and  the  varieties  which 
it  may  present  in  different  localities  are  so  slight  and  inconstant,  that 
such  references  as  I  have  already  made  to  them  may  suffice.  But  cer- 
tain examples  of  the  disease,  in  other  than  integumental  parts,  need 
separate  description. 

The  Lymphatic  Glands,  in  anatomical  relation  with  the  primary 
seat  of  an  epithelial  cancer,  usually  become  similarly  cancerous  in  the 
progress  of  the  disease ;  and,  I  think,  sooner  or  later  in  that  progress, 
in  direct  proportion  to  its  own  rapidity,  following  in  this  the  same  rate 
as  in  other  cancers.  From  the  glands  nearest  to  the  primary  seat,  the 
disease  gradually  extends  towards  the  trunk,  yet  seldom  reaches  far. 
I  have  known  the  whole  line  of  cervical  glands  affected  in  epithelial 
cancer  of  the  tongue  ;  and  the  lumbar  glands  may  become  diseased  with 
the  penis  or  scrotum  ;  but,  much  more  often,  the  proximate  cluster  of 
glands  alone  becomes  cancerous,  and  those  more  distant  are  swollen 
and  succulent,  but  contain  no  cancerous  matter.     This,  however,  must 

*  Mailer's  Archiv,  1852,  p.  178. 

f  Ueber  den  Zottenkrebs,  pp.  11,  18. 

J  In  Path.  Transact.,  vol.  viii,  p.  254,  Mr.  J.  Hutchinson  relates  a  case  of  recurrent  epi- 
thelial carcinoma  of  the  cervix  uteri,  in  which  the  cells  were  for  the  most  part  cohimnar  in 
shape,  and  many  of  them  possessed  ill-formed  cilia.  In  the  first  growth  the  cells  were  tes- 
sellated, and  of  the  usual  character.  Forster  also,  in  his  Atlas,  pi.  28,  fig.  3,  records  a  case 
of  '•  cancroid'  of  the  rectum,  in  which  the  epithelium  cells  had  the  shape  of  the  columnar 
or  cylindrical  epithelium.  These  cells  were  large,  had  finely  granular  contents,  and  large 
clear  nuclei,  with  nucleoli  of  a  similar  character.  In  many  of  the  cells  multiplication  by 
division  was  evidently  taking  place. 


EPITHELIAL    CANCER    IN    THE    LYMPHATIC     GLANDS.    617 

not  be  taken  to  imply  a  continuous  extension  of  the  disease  from  the 
primary  seat  to  the  glands ;  for  large  intervals  of  apparently  healthy 
tissues  often  intervene.  I  have  seen,  with  epithelial  cancer  of  the 
back  of  the  hand,  the  lymphatic  gland  near  the  bend  of  the  elbow  simi- 
larly cancerous  throughout;  but  the  whole  forearm  was  healthy.  I  am- 
putated an  old  man's  hand  with  a  similar  cancer ;  and  he  died  with  all 
his  axillary  glands  diseased,  but  with  no  sign  of  cancerous  lymphatics 
or  other  disease  in  the  arm.* 

In  some  cases  the  diseased  glands  appear  in  a  large  cluster,  forming 
one  lobed  mass  ;  in  others,  a  chain  of  small  glands  is  felt,  such  as  one 
might  not  suppose  to  be  cancerous,  except  for  their  hardness.  The 
cancerous  elements  in  the  glands  resemble  those  in  the  primary  disease ; 
indeed,  I  have  found  even  slight  modifications  of  general  character  in 
the  one,  exactly  repeated  in  the  other,  f  They  are  inserted  among  the 
natural  structures  of  the  gland.  At  first,  I  think,  they  usually  appear 
in  circumscribed  masses,  occupying  only  a  certain  part  of  the  gland ; 
but  these,  gradually  increasing,  at  length  exclude,  or  lead  to  the  re- 
moval of,  the  whole  of  the  original  tissues. 

The  diseased  glands  are  enlarged,  hardened,  smooth-surfaced,  and 
usually  retain  their  natural  connection  with  the  surrounding  tissues. 
On  section,  part  or  the  whole  of  the  gland  presents  the  same  appear- 
ance as  a  section  of  primary  epithelial  cancer ;  and,  generally,  the 
opaque- white  crumbling  substance,  like  scrapings  from. macerated  epi- 
dermis, is  abundant.  One  can  remove  masses  of  it,  and  leave  only  the 
capsule  of  the  gland,  or  some  remains  of  gland-substance  that  bounded 
the  spaces  that  it  filled. 

Glands  thus  diseased  are  not  unfrequently  the  seats  of  acute  inflam- 
mation, in  which,  with  fatty  degeneration  of  the  cancer-cells,  suppura- 
tion may  ensue  :  they  may  discharge  the  pus,  as  from  a  common  bubo, 
and  may  continue  many  days  thus  suppurating.  But  the  end  of  this 
is,  that  large  and  deep  cancerous  ulcers,  such  as  are  already  described, 
form  in  them  and  the  adjacent  tissues,  and  the  progress  of  these  is  often 
more  serious  than  that  of  the  primary  disease. 

I  have  seen  two  examples  of  primary  epithelial  cancer  in  lymphatic 

*  Such  cases  do  not  prove — they  only  make  it  very  probable — that  there  was  no  can- 
cerous affection  of  the  lymphatic  vessels  betvireen  the  primary  disease  and  the  glands. 
Such  continuous  disease  has  been  traced  from  scirrhous  cancers  of  the  breast  to  the  axillary 
glands ;  and  I  once  found  epithelial  cancer-cells  in  the  dental  canal,  when  primary  disease 
existed  in  the  gum  and  alveolar  part  of  the  jaw,  and  secondary  disease  in  a  submaxillary 
lymphatic  gland. 

f  In  one  case  of  epithelial  cancer  of  the  tongue,  and  in  another  of  the  larynx,  I  found  the 
lymphatic  glands  affected  with  what,  according  to  both  general  and  microscopic  characters, 
could  only  be  regarded  as  firm  medullary  cancer.  It  is  possible  that,  in  these  cases,  the  pri- 
mary disease  was  of  mixed  kinds, — medullary  and  epithelial :  just  as  there  are  examples  of 
mixed  cartilaginous  and  medullary  tumors,  in  which  only  the  medullary  disease  is  repeated 
in  the  lymphatic  glands  (see  p.  459).  But  I  found  no  evidence  of  this  mixture  of  diseases 
in  the  primary  growth  ;  and  I  think  it  equally  possible  that  the  cases  may  be  compared 
with  the  rare  instances  of  secondary  medullary,  associated  with  primary  scirrhous,  cancer. 

40 


618  EPITHELIAL    CANCER     OF    THE     LUNGS. 

glands  ;  one  I  "will  relate,  botli  for  its  own  interest,  and  because  it  illus- 
trated many  of  the  foregoing  statements.  The  man,  who  was  a  patient 
in  St.  Bartholomew's  Hospital,  was  a  sweep,  48  years  old :  his  skin 
was  dusky  and  dry,  and  many  hair-follicles  were  enlarged  by  their  ac- 
cumulated contents ;  but  he  had  no  appearance  of  cancer,  or  wart  of 
any  kind,  on  the  scrotum  or  penis :  yet  his  inguinal  glands  were  dis- 
eased just  as  they  commonly  are  in  the  later  stages  of  scrotal  soot-can- 
cer. On  the  right  side,  over  the  saphenous  opening,  a  cluster  of  glands 
formed  a  round  tuberous  mass,  more  than  an  inch  in  diameter.  It  felt 
.very  firm,  heavy,  ill-defined,  and  as  if  deep-set.  Over  its  most  promi- 
nent part  the  skin  was  adherent,  and  ulcerated,  and  a  soft  dark  growth 
protruded  through  it.  Above  this  mass  were  three  glands  enlarged, 
but  not  hardened.  On  the  left  side,  below  the  crural  arch,  one  gland 
was  enlarged  to  a  diameter  of  half  an  inch,  and  hard  ;  and  four  others 
felt  similarly  but  less  diseased.     All  these  were  movable  under  the  skin. 

This  disease  had  been  observed  in  progress  for  fifteen  weeks,  having 
begun  in  the  right  groin  as  a  hard  lump  under  the  skin,  like  those  which 
were  now  in  the  left  groin,  and  which  had  commenced  to  enlarge  some- 
what later.     The  ulceration  in  the  right  groin  had  existed  for  a  week. 

I  removed  all  the  glands  that  seemed  diseased.  The  chief  mass,  from 
the  right  side,  appeared,  on  section,  lobed,  soft,  grayish,  mottled  with 
pink  and  livid  tints.  The  same  changes,  but  with  increased  firmness, 
were  seen  in  the  largest  gland  from  the  left  side ;  and  the  material 
pressed  from  both  these  (a  turbid,  grumous,  and  not  creamy,  substance) 
contained  abundant  epithelial  cancer-cells.  The  other  glands  were  not 
evidently  cancerous  ;  but,  during  the  healing  of  the  operation  on  the 
right  side,  a  gland,  which  I  had  thought  it  unnecessary  to  remove, 
enlarged  and  became  hard  :  it  was  destroyed  with  chloride  of  zinc,  and 
then  the  wounds  healed  soundly.  The  patient  remained  well  for  at 
least  six  years. 

The  Epithelial  Cancer  of  the  Lungs,  which  I  referred  to  (p.  596)  as 
having  once  seen,  occurred  in  an  old  man  whose  penis  was  amputated 
eighteen  months  before  death.  The  disease  soon  returned  in  the  ingui- 
nal glands,  and  I  received  these  and  the  lungs  for  examination.  The 
other  organs  were  reported  healthy. 

A  cluster  of  three  or  four  glands  was  compressed  in  a  large  mass,  of 
which  a  part  protruded  through  an  ulcerated  opening  in  the  skin.  On 
section,  nearly  the  whole  of  the  gland-substance  appeared  replaced  by 
the  peculiar  and  oft-mentioned  whitish,  half-dry,  friable  substance,  with 
grayish  mottlings  and  streaked  with  bloodvessels.  In  this  substance  all 
the  structures  of  epithelial  cancer,  with  abundant  laminated  capsules, 
were  perfectly  distinct ;  they  might  have  been  taken  as  types. 

In  the  lungs  there  were  about  twenty  masses  of  similar  cancerous 
substance  ;  and  of  one  large  mass,  at  the  root  of  the  right  lung,- 1  could 
not  be  sure  whether  it  were  in  the  lung  itself  or  in  a  cluster  of  bronchial 


EPITHELIAL    CANCER     OF     THE     UTERUS    AND    VAGINA.       619 

glands.  They  were  nearly  all  spherical,  or  flattened  under  and  in  the 
pleura,  and  measured  from  ^  of  an  inch  to  nearly  3  inches  in  diameter. 
Their  substance  was  opaque-white,  marbled  with  pale  yellow  and  pink, 
intersected  by  lines  of  gray  and  black  (belonging  apparently  to  the  in- 
terlobular tissue  of  the  lungs),  and  marked  with  bloodvessels.  They 
were  compact,  but  brittle  and  crumbling  under  pressure :  several  of  the 
largest  were  softer  and  more  friable  at  their  centres  than  elsewhere, 
and  the  largest  three  had  great  central  cavities,  filled  with  softened 
cancerous  matter  and  pus :  they  might  have  been  called  "  cancerous 
vomicae  ;"  but  they  were  completely  bounded  by  layers  of  cancer,  rough 
and  knotted  on  their  inner  surfaces,  and  had  no  communication  with  air- 
tubes.  From  one  mass  an  outgrowth  projected  into,  and  had  grown 
within,  a  bronchial  tube ;  from  another  a  similar  growth  extended  into 
a  pulmonary  artery. 

The  crumbling,  brittle  texture  of  these  masses,  and  the  absence  of 
creamy  "juice"  in  even  the  softest  parts,  might  havesufiiced,  I  believe, 
to  declare  that  these  were  not  masses  of  scirrhous  or  medullary  cancer : 
but  the  microscopic  examination  left  no  doubt.  Their  minute  structures 
accorded  exactly  with  those  in  the  inguinal  glands :  not  a  character  of 
the  epithelial  cancers  was  wanting.* 

Epithelial  Cancer  in  the  Heart  is  illustrated  in  the  Museum  of  St. 
Bartholomew's. t  A  man,  58  years  old,  had  a  granulated  and  warty 
epithelial  cancer,  which  covered  the  anterior  and  inferior  third  of  his 
eye,  and  was  firmly  combined  with  the  conjunctiva  and  parts  of  the 
sclerotica  and  cornea.  Mr.  Worraald  removed  the  eyeball  with  all  the 
disease.  Two  years  afterwards,  the  man  died  with  a  large  tumor  over 
the  parotid  gland ;  and  a  mass  of  cancer,  about  an  inch  and  a  half  in 
diameter,  was  imbedded  in  the  substance  of  the  apex  of  the  right  ventricle 
and  septum  of  the  heart.  The  mass  is  soft  and  broken  at  its  centre, 
and  has  the  microscopic  structures  of  epithelial  cancer. 

In  the  Uterus,  and  the  adjacent  part  of  the  Vagina,  the  epithelial 
cancer  may  be  found  with  ordinary  characters,  such  as  were  described 
at  the  beginning  of  the  lecture ;  but  its  more  remarkable  appearance  is 
in  the  form  of  the  "  Cauliflower-Excrescence."  Only  a  part,  however, 
of  the  cases  to  which  this  name  has  been  ascribed  have  been  epithelial 
cancers:  of  the  rest  some  were  medullary  cancers,  and  some,  perhaps, 
simple,  non-cancerous,  warty,  or  papillary  growths. 

My  own  observations  of  this  disease  have  only  sufficed  to  confirm 
(wherever  I  could  test  them)  those  far  more  completely  made  by  Vir- 

*  Portions  of  the  Inngs  and  of  the  inguinal  glands,  in  this  and  in  the  last-described  case, 
are  in  the  Museum  of  St.  Bartholomew's. 

f  Series  xii,  60.  In  the  Catalogue  the  disease  is  described  as  medullary  cancer;  but  I 
have  recently  examined  microscopically  both  it  and  the  primary  growth  (Series  ix,  No.  17); 
and  they  are  certainly  epithelial  cancers. 


620  CAULIFLOWER-EXCRESCENCE. 

chow,*  whose  results,  approved  by  Lebert,  and  consistent  with  the  best 
earlier  records,  I  shall  therefore  quote:  "  One  must  distinguish  three 
different  papillary  tumors  at  the  os  uteri, — the  simple,  such  as  Frerichsf 
and  LebertJ  have  seen ;  the  cancroid ;  and  the  cancerous" — [i.  e.  the 
epithelial-cancerous  and  the  medullary-cancerous]  :  the  first  two  forms 
together  constitute  the  cauliflower-growth.  This  begins  as  a  simple 
papillary  tumor,  and  at  a  later  period  passes  into  cancroid  [epithelial 
cancer].  At  first  one  sees  only  on  the  surface  papillary  or  villous 
growths,  which  consist  of  very  thick  layers  of  peripheral  flat,  and  in- 
terior cylindrical,  epithelial  cells,  and  a  very  fine  interior  cylinder 
formed  of  an  extremely  little  connective  tissue  with  large  vessels.  The 
outer  layer  contains  cells  of  all  sizes  and  stages  of  development ;  some 
of  them  forming  great  parent-structures  with  endogenous  corpuscles. 
The  vessels  are,  for  the  most  part,  colossal,  very  thin-walled  capillaries, 
which  form  either  simple  loops  at  the  apices  of  the  villi,  between  the 
epithelial  layers,  or  towards  the  surface  develop  new  loops  in  constantly 
increasing  number,  or,  lastly,  present  a  reticulate  branching.  At  the 
beginning  of  the  disease  the  villi  are  simple  and  close  pressed,  so  that 
the  surface  appears  only  granulated,  as  Clarke  describes  it :  it  becomes 
cauliflower-like  by  the  branching  of  the  papillse,  which  at  last  grow  out 
to  fringes  an  inch  long,  and  may  present  almost  the  appearance  of  an 
hydatid-mole. 

"  After  the  process  has  existed  for  some  time  on  the  surface,  the  can- 
croid alveoli  begin  to  form  deep  between  the  layers  of  the  muscular  and 
the  connective  tissues  of  the  organ.  In  the  early  cases  I  saw  only 
cavities  simply  filled  with  epithelial  structures ;  but  in  Kiwisch's  case 
there  were  alveoli,  on  whose  walls  new,  papillary,  branching  growths 
were  seated, — a  kind  of  proliferous  arborescent  formation." 

It  will  be  evident,  from  this  description,  that  the  cauliflower-excres- 
cence, in  the  two  conditions  distinguished  by  Yirchow,  illustrates  the 
usual  history  of  the  most  exuberant  epithelial  cancers  (p.  599) :  it  might 
be  taken  as  the  principal  example  of  the  group.  That  which  he  calls 
the  "  simple  papillary  tumor"  is  an  excessive  papillary  outgrowth  of 
epithelial  cancer ;  the  later  stage  of  the  same,  when  it  "  passes  into 
cancroid,"  is  the  usual  extension  of  such  a  cancer  into  deeper  parts, — 
a  continuous  growth  of  the  same  thing  in  a  new  direction.  For  the 
papillary  structures,  composed,  as  Virchow  says,  of  epithelial  cells  with 
bloodvessels  and  a  very  little  connective  tissue,  are  the  essential  cha- 
racters of  the  epithelial  cancerous  outgrowths ;  and  I  believe  that  the 
same  composition  has  never  been  seen  in  any  papillary  or  warty  growths, 
that  did  not,  if  time  were  allowed,  proceed  to  the  formation  of  epithelial 
structures  in  the  deeper  parts,  and  thence  through  the  usual  progress 
of  malignant  disease. 

*  Wurzburg  Verhandl.,  1850,  B.  i,  109.     They  were  chiefly  made  in  the  cases  described 
by  Mayer  in  the  Verhandl.  der  Gesellsch.  fur  Gebiirtshiilfe  in  Berlin,  1851,  p.  111. 
f  Jen^isphe  Annalen,  p.  7.  J  Abhandlungen,  pp.  57,  150. 


RODENT    ULCERS.  621 

Before  entering  on  the  pathology  of  epithelial  cancers  it  will  be  useful 
to  refer  briefly  to  the  morbid  anatomy  of  the  diseases  with  which  they 
have  most  affinity,  and  from  which  it  is  most  necessary  to  distinguish 
them, — at  least,  as  clearly  as  we  can.  These  are,  on  the  one  side,  the 
scirrhous  and  medullary  cancers  ;  and,  on  the  other,  certain  rodent 
ulcers  and  warty  growths  of  scars.* 

The  descriptions  in  former  lectures  of  the  scirrhous  and  medullary 
cancers  of  the  skin  and  subcutaneous  tissue  may  suffice  for  the  distinc- 
tion from  them  (compare  pp.  533,  535,  579). 

The  Rodent  Ulcer  is  the  disease  which  has  been  described  under 
various  names  :  such  as  cancerous  ulcer  of  the  face,  cancroid  ulcer, 
ulcere  rongeant,  ulcere  chancreux  du  visage,  der  flache  Krebs,  moosar- 
tige  Parasit,  ulcus  exedens,  noli  me  tangere.  In  its  earliest  appear- 
ance, on  its  most  frequent  seat,  it  has  been  called  cancerous  tubercle  of 
the  face.  It  has  been  confounded  by  many  with  different  forms  of 
cancer ;  yet  it  is  distinct  from  them  in  structure  as  well  as  in  history, 
and  had  better  be  described  by  some  name  which  may  not  add  to  the 
yearly  increasing  confusion  that  arises  from  the  use  of  terms  expressing 
likeness  to  cancer. 

Sir  B.  C.  Brodie  thus  describes  the  most  frequent  characters  of  the 
disease  :t  "  A  man  has  a  soft  tubercle  upon  the  face,  covered  by  a 
smooth  skin.  He  may  call  it  a  wart,  but  it  is  quite  a  different  thing. 
On  cutting  into  it  you  find  it  consists  of  a  brown  solid  substance,  not 
very  highly  organized.  A  tumor  of  this  kind  may  remain  on  the  face 
unaltered  for  years,  and  then,  when  the  patient  gets  old,  it  may  begin 
to  ulcerate.  The  ulcer  spreads  slowly  but  constantly,  and,  if  it  be  left 
alone,  it  may  destroy  the  whole  of  the  cheek,  the  bones  of  the  face,  and 
ultimately  the  patient's  life  ;  but  it  may  take  some  years  to  run  this 
course.  So  far  these  tumors  in  the  face,  and  these  ulcers,  are  to  be 
considered  as  malignant.  Nevertheless,  they  are  not  like  fungus  hse- 
matodes  or  cancer ;  and  for  this  reason,  that  the  disease  is  entirely 
local.  It  does  not  affect  the  lymphatic  glands,  nor  do  similar  tumors 
appear  in  other  parts  of  the  body." 

The  constantly  progressive  ulceration  is  a  character  in  which  this 
disease  resembles  cancer,  especially  epithelial  cancer.  The  likeness  in 
this  respect  may  indicate  some  important  affinity  between  them,  but  the 
differences  between  them  are  greater ;  for  not  only  is  the  rodent  ulcer 
usually  unlike  that  of  any  cancer  in  its  aspect,  rate,  and  mode  of  pro- 
gress, but  the  tissues  bounding  it,  and  forming  its  base  and  walls,  never 

*  The  whole  of  this  subject  is  admirably  illustrated  by  Mr.  Csesar  Hawkins,  in  papers 
in  the  Medico-Chir.  Trans.,  vols,  xix  and  xxi,  and  in  the  Medical  Gazette,  vols,  xxviii,  xxix. 
Indeed,  I  can  add  nothing  to  his  account,  except  such  conclusions  as  are  derived  from  mi- 
croscopic examinations  of  the  diseases.  One  of  Mr.  Hawkins'  lectures  relates  to  cheloid 
growths;  but  to  these  it  seems  unnecessary  to  refer;  if  they  could  be  confounded  with  any 
form  of  cancer,  it  would  be  with  scirrhous  cancer  of  the  skin. 

■j"  In  his  Lectures  on  Pathology  and  Surgery,  p.  333. 


622  EODENT     ULCERS. 

contain  any  epithelial  or  other  cancerous  structure ;  they  are  infiltrated 
with  only  such  structures  as  may  he  found  in  the  walls  of  common  chronic 
ulcers. 

The  most  usual  characters  of  the  rodent  ulcer,  whether  on  the  cheek, 
the  eyelids,  upper  lip,  nose,  scalp,  vulva,  or  any  other  part,  are  as  fol- 
lows:* It  is  of  irregular  shape,  hut  generally  tends  towards  oval  or  cir- 
cular. The  hase,  however  deeply  and  unequally  excavated,  is  usually, 
in  most  parts,  not  warty  or  nodular,  or  even  plainly  granulated  ;  in 
contrast  with  cancerous  ulcers,  one  may  especially  ohserve  this  ahsence, 
or  less  amount,  of  up-growth.  It  is,  also,  comparatively  dry  and  glossy, 
yielding,  for  its  extent,  very  little  ichor  or  other  discharge,  and  has 
commonly  a  dull  reddish-yellow  tint.  Its  horder  is  slightly,  if  at  all, 
elevated ;  if  elevated,  it  is  not  commonly  or  much  either  everted  or 
undermined,  hut  is  smoothly  rounded  or  lowly  tuherculated.  The  im- 
mediately adjacent  skin  usually  appears  quite  healthy.  The  hase  and 
horder  alike  feel  tough  and  hard,  as  if  hounded  hy  a  layer  of  indurated 
tissue  ahout  a  line  in  thickness-.  This  layer  does  not  much  increase  in 
thickness  as  the  ulcer  extends  ;  and  herein  is  another  chief  contrast 
with  cancerous  ulceration  :  in  the  progress  of  the  rodent  ulcer  we  see 
mere  destruction  ;  in  the  cancerous  we  see  destruction  with  coincident, 
and  usually  more  than  commensurate,  growth.  It  is  only  in  the  rarest 
cases  that  a  growth  is  associated  with  rodent  ulcer.  In  one  such  case, 
a  gentleman  about  55  years  old  had,  for  nine  years,  a  well-marked  ro- 
dent ulcer  of  the  ear,  which  was  several  times  partially  healed.  At 
length,  a  firm  spheroidal  growth,  nearly  an  inch  in  diameter,  appeared 
in  the  subcutaneous  tissue  at  the  border  of  the  ulcer.  I  cut  off  the 
upper  half  of  the  ear  with  the  adjacent  growth,  expecting  to  find  that 
it  was  an  epithelial  cancer;  but  it  had  no  cancer  structures  ;  only  such 
corpuscles  as  I  have  always  found  in  the  borders  and  bases  of  the  rodent 
ulcers. 

This  indurated  substance  at  the  base  and  borders  of  the  ulcer  appears, 
on  section,  very  firm,  pale  grayish,  uniform  or  obscurely  fibrous ;  little 
fluid  of  any  kind  can  be  pressed  from  it.  It  is  composed  of  the  same 
elementary  structures  as  common  granulations  are,  and  these,  in  the 
deeper  layers,  are  inserted  among  the  tissues  on  which  the  ulcer  rests. 
I  have  examined  very  carefully  six  of  these  ulcers,  removed  hy  excision, 
and  have  never  seen  in  or  near  them  a  structure  resembling  those  of 
epithelial  or  any  other  form  of  cancer.  Lebert's  observations,  I  believe, 
fully  coincide  with  mine  ;  though  he  classes  the  disease  with  epithelial 
cancers,  under  the  general  name  of  Cancroid.  Mr.  Jonathan  Hutchin- 
son, also,  has  made  several  examinations  of  pieces  cut,  during  life,  from 

*  The  parts  enumerated  were  the  seats  of  disease  in  the  cases  from  which  I  have  drawn 
my  description,  and  in  which  it  is,  I  beUeve,  most  frequent ;  but  it  is  not  confined  to  them. 
Lebert  refers  to  cases  of  it,  in  his  account  of  the  cancroid  of  the  uterus,  and  suggests  (what 
is  highly  probable)  that  the  simple  chronic,  or  perforating,  ulcer  of  the  stomach  is  a  disease 
of  the  same  natiu^e. 


CANCER     OF    SCARS.  623 

the  margins  of  rodent  ulcers,  and  always  with  the  same  result :  they 
never  contained  structures  resembling  those  of  epithelial  or  any  other 
cancer. 

Thus  the  anatomical  distinction  between  this  disease  and  cancer  is 
evident,  and  they  are  equally  different  in  pathology ;  the  rodent  ulcer, 
so  far  as  it  has  been  observed,  is  never  attended  by  similar  disease  in 
the  lymphatics  or  any  other  part ;  and  if  completely  removed  or  de- 
stroyed, it  does  not  recur. 

The  Warty  G-roioths  on  Scars  (Cancers  of  Cicatrices)  are  usually 
well-marked  papillary  epithelial  cancers,  which  grow  in  the  place  of 
scars  remaining  after  injuries  or  common  ulcers.  Mr.  Hawkins,*  who 
has  given  a  very  full  account  of  their  general  characters  and  progress, 
describes  cases  in  the  scars  of  burns,  gunshot-wounds,  floggings,  and 
ulcers.  All  that  I  have  seen  were  on  the  lower  extremities,  and  con- 
nected with  scars  after  repeated  injuries. f 

The  description  already  given  of  the  warty  epithelial  cancers  may 
sufiice  for  these.  They  usually  exemplify  very  well  the  widespread 
growth  and  cancerous  change  in  the  papillae ;  the  enlargement,  at  first 
probably  simple,  and  afterwards  with  cancerous  formation,  in  the  pa- 
pillae of  the  adjacent  skin  ;  the  deep  extension  of  the  disease  to  the  peri- 
osteum, and  thence  onwards,  even  to  the  complete  penetration  of  the 
bones  and  other  subjacent  tissues ;  and,  at  a  late  period,  the  cancerous 
disease  of  the  lymphatic  glands.  But  it  is  important  to  be  aware 
that  this  disease  may  be  closely  imitated  by  warty  growths  and  ulcers, 
in  and  about  which  no  cancerous  matter  can  be  found.  I  examined  very 
carefully  such  an  ulcer  with  prominent  growths  on  the  front  of  a  man's 
leg.  It  was  seated  in  the  middle  third  of  the  leg,  in  the  place  of  a 
large  old  scar  after  a  scald,  and  the  greater  part  of  the  ulcer  presented 
high,  lobed  and  nodulated,  hard  granulations.  No  one  doubted,  before 
the  amputation,  that  the  disease  was  the  usual  form  of  cancer  ensuing 
in  these  conditions ;  yet  no  cancerous  structure  could  be  found ;  in 
whichever  part  I  examined,  I  could  find  only  inflammatory  products, 
and  such  corpuscles  as  compose  ill-developed  or  degenerate  granulations 
upon  common  ulcers.  Similar  warty  diseases,  very  closely  resembling, 
to  the  naked  eye,  the  epithelial  cancers,  and  often,  like  them,  ulcerat- 
ing, are  not  very  rare  on  the  lower  lip  ;  and  I  have  seen  them  on  the 
tongue. I 

I  think  some  of  the  diversities  of  opinion  respecting  the  nature  of 
these  warty  growths  and  ulcers  may  be  due  to  the  want  of  distinction 
between  those  which  are,  and  those  which  are  not,  epithelial  cancers. 

*  Medical  Gazette,  vol.  xxviii,  872  ;  and  Med.-Chir.  Trans.,  xix.  See,  also,  the  Dublin 
Quarterly  Journal,  1850-51. 

t  They  are  amply  illustrated  in  the  Museum  of  St.  Bartholomew's,  Ser.  i,  and  Ser.  xxxv, 
40.  Several  cases  are  described  by  Mr.  Stanley  (Treatise  on  Diseases  of  the  Bones,  p.  360). 

X  The  growths  described  by  some  of  the  German  pathologists,  by  the  name  of  destructive 
papillary  tumor  of  the  skin,  are  doubtless  the  same  as  these  ulcerating  warty  growths. 


624      EPITHELIAL  CANCER  —  INFLUENCE  OF  SEX. 

Certainly,  the  opinion  that  epithelial  cancer  is  thoroughly  curable  by 
operation,  and  is  altogether  a  much  less  malignant  disease  than  the 
other  varieties  of  cancer,  is  due,  in  great  part,  to  warty  growths  and 
ulcers  having  been  considered  cancerous,  which  were  not  so.  To  the 
naked  eye  and  during  life,  the  two  diseases  may  be  very  much  alike ; 
but  the  difference  in  their  respective  minute  structures  is  clear,  and  in- 
dicates essential  difference  of  nature :  certainly,  in  the  pathology  of 
epithelial  cancer,  caution  is  necessary  in  reckoning  any  of  these  cases 
that  have  not  been  microscopically  examined. 

I  would  add,  that  I  have  no  doubt  that  the  epithelial  growth,  in  some 
cases,  proceeds  from  the  periosteum  or  other  subcutaneous  tissues,  and 
thence  extends  into  and  through  the  skin.  I  have  seen  the  growth  pro- 
truding through  an  ulcerated  aperture  in  the  scar,  just  as  any  deep- 
seated  tumor  might.  Such  cases  justify  Mr.  Stanley's  description  of 
the  disease  as  one,  primarily,  of  the  periosteum. 


LECTURE   XXXII. 

EPITHELIAL    CANCER. 
PART    II. — PATHOLOGY. 

Among  all  the  cancers,  the  epithelial  present  the  general  or  constitu- 
tional features  of  malignant  disease  in  the  least  intense  form.  They 
commence  at  the  latest  average  period  of  life ;  they  appear  to  be  most 
dependent  upon  local  conditions  ;  they  are  least  prone  to  multiplication 
in  internal  organs  ;  they  are  associated  with  the  least  evident  diathesis 
or  cachexia.  And  yet  I  believe  that  in  a  large  survey  of  them,  none 
of  the  features  of  malignant  disease,  as  exemplified  in  the  scirrhous  and 
medullary  cancers,  will  be  found  wanting :  the  difference  is  one  of  degree, 
not  of  kind. 

(a)  A  large  majority  of  the  cases  of  epithelial  cancers  occur  in  males. 
In  105  cases,  affecting  parts  common  to  both  sexes,  86  were  in  men, 
and  19  in  women.  In  the  cases  affecting  the  sexual  organs  themselves, 
I  think  the  proportion  is  nearly  equal ;  unless  we  reckon  the  scrotal 
soot-cancers,  which,  for  obvious  reasons,  we  should  more  properly  ex- 
clude. 

(6)  A  few  cases  are  on  record,  transmitted  from  book  to  book,  in 
which  what  were  probably  epithelial  cancers  occurred  before  adult  life. 
Sir  James  Earle  saw  a  scrotal  soot-cancer  in  a  child  eight  years  old  ;* 

*  Pott's  Works  by  Earle,  iii,  p.  178. 


EPITHELIAL  CANCER INFLUENCE  OF  AGE. 


625 


so  did  Mr.  Wadd;*  and  M.  Lebertf  examined  a  "cancroid"  growth  at 
the  vulva  in  a  child  3|-  years  old,  in  whom  it  was  almost  congenital. 
But  cases  such  as  these  cannot  be  taken  into  our  estimate  of  the  influ- 
ence of  age  in  determining  the  access  of  the  disease.  In  the  following 
table,  I  have  included  no  cases  that  were  recorded  merely  or  chiefly  on 
account  of  the  patients'  ages  :% 

No.  of  Cases. 

9 

22 

40 

32 

.    ■ 30 

10 


Age. 

20 

to  30 

30 

"  40 

40 

"  50 

50 

"  60 

60 

"  70 

70 

«  80 

143 

If  now,  as  in  the  last  two  lectures  (pages  543,  582),  we  calculate, 
from  this  table,  the  frequency  of  epithelial  cancer  in  proportion  to  the 
number  of  persons  living  at  each  of  the  successive  periods,  it  may  be 
represented  by  the  following  numbers  (100  being,  as  before,  taken  to 
express  the  frequency  between  40  and  50) : 


20  to  30 

years, 

12 

30  "  40 

a 

41 

40  «  50 

u 

.   100 

50  "  60 

" 

.   119 

60  "  70 

li 

.   163 

70  "  80 

u 

111 

We  may  probably  deduce  from  this  calculation,  which  is  confirmed 
by  Mr.  Baker's  tables,§  that  the  conditions  favorable  to  the  production 
of  epithelial  cancers  regularly  increase  with  the  increase  of  age  ;  for 
the  apparent  diminution  after  70  may  be  reasonably  ascribed  to  the 
comparatively  small  proportion  of  persons  beyond  that  age  who  are  re- 
ceived into  hospitals,  or  who  are  under  such  surgical  treatment  as  to 
have  their  cases  recorded. 

The  proportions  expressed  by  the  foregoing  general  tables  are  nearly 
true  for  the  epithelial  cancers  of  each  part  most  liable  to  be  afl"ected  : 
the  only  notable  peculiarities,  I  believe,  are,  that  the  mean  age  of  its 


*  Curling  on  the  Diseases  of  the  Testis,  iii,  p.  528. 

f  Traite  Pratique,  p.  676.  Hannover  (Das  Epithelioma,  p.  104)  quotes  from  Frerichs  a 
case  in  which  the  disease  extended  from  the  ear  through  the  petrous  bone  in  a  male  19 
years  old. 

J  The  table  includes  cases  from  Lebert,  Hannover,  and  others.  But  I  have  omitted,  both 
from  it,  and  from  the  preceding  one,  Lebert's  cases  of  "  cancroid"  of  the  face.  They  were 
examples  of  rodent  ulcers,  and  their  contrast  with  epithelial  cancers  (of  the  lip,  for  ex- 
ample) is  well  shown,  in  that  the  average  age  for  their  coming  under  operation  is  17  years 
later,  and  the  proportionate  frequencies  in  the  two  sexes  is  reversed.  The  ages  assigned  in 
the  above  table  are,  with  few  exceptions,  those  at  which  the  disease  was  first  observed  by 
the  patients. 

I  Med.-Chir.  Trans.,  vol.  xlv. 


626  EPITHELIAL     CANCER. 

occurrence  is  lowest  in  the  sexual  organs,  and  highest  in  the  integu- 
ments of  the  head,  face,  eyelids,  and  upper  extremities. 

(c)  An  hereditary  disposition  to  soot-cancer  has  been  several  times 
observed:  as  by  Mr.  Earle,*  in  a  grandfather,  father,  and  two  sons ;  by 
Mr.  Hawkins, t  in  a  father  and  son ;  by  Mr.  Cusack,|  in  a  mother  and 
son ;  by  myself  (twice)  in  two  brothers.  But  all  the  persons  here  re- 
ferred to  were  engaged  in  the  same  trade,  and  their  exposure  to  the 
same  exciting  or  predisposing  cause  of  the  disease  diminishes  the  value 
of  the  facts  as  indications  of  hereditary  predisposition.  I  have  no  cer- 
tain record  of  other  epithelial  cancers  occurring  in  many  members  of 
the  same  family;  but  among  66  patients  with  epithelial  cancer,  10  were 
members  of  families  in  which  other  members  have  had  scirrhous  or  me- 
dullary cancers,  and  two  were  sweeps,  whose  brothers  had  similar  soot- 
cancers. 

Among  160  instances  of  cancer,  in  most  of  which  the  point  was  in- 
quired into,  though  none  were  collected  for  the  sake  of  it,  these  cases 
were  found :  (1)  A  man  had  medullary  cancer  of  a  toe :  his  father  had 
cancer  of  the  lip.  (2)  A  woman  had  repeated  epithelial  cancers  of  the 
labia;  her  sister,  her  father's  sister,  and  her  mother's  brother's 
daughter,  had  cancer  of  the  breast,  (3)  A  man  had  epithelial  cancer 
of  the  lip,  whose  grandmother  had  cancer  of  the  breast.  (4)  A  gentle- 
man had  epithelial  cancer  of  the  interior  of  the  cheek :  his  aunt  died 
with  cancer  of  the  breast.  (5)  A  woman  had  medullary  cancer  of  the 
breast :  her  mother  had  cancer  of  the  uterus,  and  her  uncle  cancer  of 
the  face.  (6)  A  woman  had  scirrhous  cancer  of  the  breast,  whose 
mother's  uncle  had  cancer  of  the  lip.  (7)  Of  another  woman  with 
similar  cancer,  one  cousin  had  cancer  of  the  lip,  another  cousin  cancer 
of  the  uterus.  (8)  A  third  woman  had  scirrhous  cancer  of  the  breast, 
whose  grandfather  had  cancer  of  the  lip.§ 

The  proportion  of  these  cases  (only  jo^h  of  tbie  whole  number)  may 
seem  too  small  to  be  even  suggestive ;  yet  it  is  too  large  to  be  referred 
to  chance.  Let  it  be  contrasted  Avith  these  facts :  (1)  I  have  found  that 
among  116  patients||  with  cancer,  only  one  was  aware  of  any  member 
of  the  same  family  having  had  a  simple  tumor.  This  was  a  woman 
with  scirrhous  cancer  of  the  breast,  from  whose  sister  a  myeloid  tumor 

*  Med.-Chir.  Trans.,  xii,  30n.  t  Medical  Gazette,  xxi,  S42. 

X  Quoted  by  Mr.  Curling  (On  Diseases  of  the  Testis,  p.  528). 

I  Dr.  Warren  mentions  this:  A  grandfather  died  with  a  cancer  of  the  lip.  His  son  and 
two  daughters  died  with  cancer  of  the  breast.  One  of  his  grandsons  and  one  of  his  grand- 
daughters had  also  cancer  of  the  breast  (On  Tumors,  p.  281).  It  maybe  objected  by  some, 
that  the  cancers  of  the  lip  here  referred  to  were  not  epithelial.  I  assume  that  they  were, 
because  of  the  exceeding  rarity  of  any  other  kind  in  the  lip :  indeed,  I  have  not  yet  seen 
one,  or  a  complete  record  of  one,  in  which  the  microscope  did  not  find  the  epithelial 
structures. 

II  These  were  part  of  the  160  mentioned  above:  but  I  have  here  reckoned  only  the  cases 
recorded  by  myself,  because  it  is  probable  that,  even  if,  among  the  others,  any  instances 
had  occurred  of  innocent  and  malignant  tumors  in  the  same  family,  they  would  not  have 
been  mentioned. 


INFLUENCE    OF    INJUEY    AND     PREVIOUS    DISEASE.       627 

of  the  breast  had  been  removed.  (2)  Among  77  patients  with  non- 
cancerous tumors,  10  were  aware  of  near  relations  having  had  similar 
diseases :  but  among  the  same  77,  the  only  cases  of  family  connection 
with  cancers  were  the  folloAving  :  [a]  The  cases  of  recurring  and  dis- 
orderly-growing mammary  tumor  related  at  p.  491  ;  (b)  the  case  of 
anomalous  cartilaginous  tumors  at  p.  446 ;  (<?)  that  of  the  same  woman 
whose  case  was  just  mentioned  as  one  of  myeloid  tumor  of  the  breast : 
five  years  after  its  removal,  she  and  her  sister  were  at  the  same  time  in 
St.  Bartholomew's  with  scirrhous  breasts ;  [d)  that  of  a  lad  with  mixed 
cartilaginous  and  glandular  tumor  over  his  parotid  gland,  whose  grand- 
mother had  cancer  of  the  breast.  Now  of  tbese  cases  the  first  two  must 
be  regarded,  I  believe,  as  instances  of  a  cancerous  disposition,  modified 
and  gradually  ceasing  in  its  transmission  from  parent  to  ofi'spring  (see  p. 
491,  &c.) ;  the  third  is  a  very  anomalous  one,  exemplifying  the  forma- 
tion of  a  most  rare  tumor  in  the  breast,  not  long  before  it  became  can- 
cerous ;  the  fourth  alone  is  an  instance  of  an  ordinary  simple  or  inno- 
cent tumor  growing  in  one  who  had  a  cancerous  relation. 

I  have  referred  to  these  cases,  not  to  suggest  that  when  cancer  has 
occurred  in  one  or  more  members  of  a  family,  the  rest  are  peculiarly 
unlikely  to  have  innocent  tumors,  but  to  show,  by  contrast,  that  the 
proportion  of  cases  in  which  epithelial  and  other  cancers  occur,  in  the 
same  family  is,  relatively,  considerable.  For  if  that  proportion  were 
the  result  of  chance  coincidences  or  errors  in  observation,  an  equal  or 
nearly  equal  proportion  of  coincidences  should  have  appeared  in  the 
opposite  set  of  cases.  But  the  contrast  between  the  two  sets  of  cases 
is  remarkable  ;  and  I  believe  the  facts  may  be  justly  regarded  as  evi- 
dence for  the  close  affinity  between  epithelial  and  other  cancers,  and  as 
an  illustration  of  the  modification  which  the  cancerous  and  other  dia- 
theses may  undergo  in  their  hereditary  transmission. 

[d)  Among  34  patients  with  epithelial  cancers,  19  were  aware  of  in- 
jury or  previous  morbid  condition  in  the  affected  part, — a  much  larger 
proportion  than  is  found  among  patients  laboring  under  tumors  of  any 
other  kind,  except  melanoid  cancers  of  the  skin. 

In  certain  cases,  injury  by  violence  appears  as  the  exciting  cause. 
But  the  histories  of  epithelial  cancers  differ  from  those  of  others  in  that 
the  kind  of  injury  which  is  most  effective  in  their  production  is  such  as 
is  often  inflicted, — frequent  blows  or  slight  wounds  on  the  same  part ; 
hurts  of  scars  and  other  seats  of  old  injury.  It  is  as  if  it  were  neces- 
sary that  the  part  should  be  considerably  changed  in  structure  before 
it  is  appropriate  for  a  cancerous  growth. 

It  agrees  with  this  that,  in  the  majority  of  cases,  patients  assign  as 
the  cause  of  the  disease,  not  injury,  or  not  it  alone,  but  some  former  dis- 
ease, especially  such  as  arises  from  long-continued  irritation  of  a  part. 
Thus  epithelial  cancers  arise  sometimes  in  old  ulcers,  as  on  the  legs, 
or,  as  I  have  known,  in  perineal  urinary  fistulse ;  sometimes,  in  those 
of  more  rapid  progress,  as  I  once  saw  in  a  case  of  necrosis  of  the  hard 


628  EPITHELIAL     CANCER. 

palate,  and  once  in  a  case  of  necrosis  of  the  angle  of  tlie  lower  jaw,  and 
as  Frerichs  describes,  in  an  ulceration  of  the  internal  ear,  following 
scarlet  fever.  The  majority  of  the  epithelial  cancers  of  the  prepuce 
and  glans  occur  in  those  who  are  the  subjects  of  congenital  phymosis, 
and  in  whom  we  may  assume  the  frequent  irritation  of  the  part  by  de- 
composed secretions.  In  some  rare  cases,  a  mole  or  pigmentary  nsevus 
becomes  the  seat  of  the  disease.  But,  among  all  the  things  referred  to 
by  patients,  none  are  so  frequently  named  as  "warts."* 

The  affections  thus  named  are  not  usually  such  as  are  commonly 
called  warts.  They  are  not  usually  like  the  warts  (Verrucse,  or  Condy- 
lomata elevata)  that  grow  on  the  genital  organs  during  gonorrhoeal  or 
other  similar  irritation ;  nor  like  such  warts  (Verrucae  vulgares)  as  are 
common  on  the  hands  of  young  people  before  puberty ;  nor  like  the 
condylomata  (C.  lata)  of  syphilis.  Such  papillary  growths  as  these 
may,  I  believe,  precede  epithelial  cancer;  but  I  think  they  rarely  do  so. 
The  general  condition  of  the  "  wart"  is,  I  think,  that  a  small  portion 
of  the  cutis  is  slightly  indurated  ;  its  papillae  are,  generally,  in  some 
measure  enlarged :  and  it  is  covered  with  a  darkish  dry  crust,  or  with  a 
scab,  or,  if  the  part  be  very  moist,  with  a  soft  layer  of  detached  scales. f 
The  induration  of  the  cutis,  and  the  predominance  of  the  crust  or  other 
covering  (which  apparently  constitutes  more  of  the  disease  than  either 
the  induration  or  the  papillae)  mark  the  chief  differences  between  this 
disease  and  any  of  the  "  warts  "  just  referred  to.  The  induration  which 
patients  often  describe  as  "  a  little  hard  knot,"  is  usually  attended  with 
elevation,  but  sometimes  with  contraction  and  depression  of  the  piece 
of  cutis.  The  crust  consists,  for  the  most  part,  of  epidermal  scales  held 
together  by  dried  secretion,  or,  in  its  deepest  layers,  forming  whitish 
friable  substance  and  fitting  between  the  papillae.  It  is  easily  detached 
and  quickly  removed;  and,  when  it  is  removed,  the  subjacent  cutis 
does  not  usually  appear  raw  or  bleeding,  but  is  tender,  florid,  and  as  if 
covered  with  a  very  thin  glossy  layer  of  epidermis.  TVhen  a  moister 
yellow  scab  covers  the  induration,  the  surface  beneath  it  is  usually  more 
inflamed  and  excoriated,  and  the  papillae  are  more  enlarged. 

Such  incrusted  warts  as  these  are  very  common,  especially  on  the 
faces  of  old  persons :  the  large  majority  of  them  lead  to  no  further 
trouble  ;J  yet  some  become  the  seats  of  epithelial  cancers,  and  some  of 
rodent  ulcers.  A  similar  affection  often  precedes  the  epithelial  cancer 
of  the  lower  lip.     Some  slight  violence  often  applied,  such  as  that  of  a 

*  It  is  implied  here  that  the  form  of  cancer  assumed  in  or  by  warts,  is  always  the  epi- 
thelial. Some  cases  by  Mr.  Butcher  (Dublin  Quarty.  J.  of  Med.  Sc,  Nov.,  1856)  appear 
to  be  instances  of  medullary  cancer  originating  in  warts. 

f  Such  as  these  are  well  described  by  Schuh  (Pseudoplasmen,  p.  46),  under  the  title 
"  barky  warts."  With  the  same  intimation  of  likeness,  Dr.  Warren  (On  Tumors,  p.  27) 
called  the  disease  "  Lepoides. '' 

J  Virchow  (in  his  Archiv,  B.  vi,  H.  iii,  p.  553)  says  that  the  small  hairy  knots,  which  are 
so  frequent  on  the  faces  of  old  persons,  have  exactly  the  structure  of  the  cutaneous  cavernous 
tumors.     But  these,  I  think,  are  not  peculiarly  apt  to  be  seats  of  epithelial  cancer. 


INFLUENCE    OF    INJURY    AND    PREVIOUS    DISEASE.        629 

short  pipe  habitually  supported  by  the  lip,  or  the  frequent  slight  rend- 
ing of  the  surface  of  a  dry  scaly  lip,  or  one  much  exposed  to  the  weather, 
leads  to  a  "little  crack  :"  this  scabs  over,  and  after  repeated  removals 
and  renewals  of  the  scab,  there  is  a  "little  hard  lump"  or  "a  sort  of 
wart,"  with  a  head  or  crust.  And  such  a  wart  might  be  as  often  in- 
nocuous on  the  lip  as  on  the  face,  if  it  were  not  that  the  lip  is  in  the 
unhappy  singularity  of  being  within  easy  reach,  at  once,  of  the  fingers, 
the  teeth,  the  tongue,  and  the  other  lip  ;  so  that  when  it  is  as  yet  but 
slightly  diseased,  it  is  never  left  at  rest. 

A.  similar  drily  scaled  or  incrusted  warty  change  of  the  cutis  often, 
I  believe,  precedes  the  chimney-sweep's  cancer ;  and  I  suspect  that  the 
true  influence  of  the  soot  in  this  disease  is  not  that  its  continued  contact 
determines  the  growth  of  cancers,  but  (at  least  in  part)  that  it  produces 
a  state  of  skin  which  provides  an  apt  locality  for  epithelial  cancer  in 
persons  of  cancerous  diathesis.  How  it  does  this  I  cannot  imagine : 
but  this  is  only  one  of  many  things  unexplained  in  this  strange  dis- 
ease ;  for  the  whole  of  the  peculiarities  of  the  chimney-sweep's  cancer — 
its  dependence  on  soot,  while  coal-dust  is  wholly  inoperative  (for  the 
disease  is  unknown  among  colliers) ;  its  comparative  frequency  in  Eng- 
land, especially  in  the  large  towns,  while  in  other  countries  where  soot 
is  abundant  it  is  hardly  seen ;  its  selection  of  the  scrotum  for  its  most 
frequent  seat, — all  these,  and  many  like  facts  in  its  history,  appear 
completely  inexplicable.  Still,  it  is  certain  that  scaly  or  incrusted 
small  warts,  such  as  I  have  been  describing,  are  very  common  in  chim- 
ney-sweeps. In  many  of  them,  even  when  they  are  thoroughly  cleaned, 
the  whole  skin  is  dry,  harsh,  and  dusky ;  and,  before  operation  for  the 
removal  of  scrotal  cancers  in  them,  it  is  a  common  question  whether 
one  or  more  warts  or  scaly  patches  near  the  chief  disease  should  be  re- 
moved with  it.  Nor  are  such  warts  confined  to  the  scrotum ;  they  may 
exist  on  every  part  of  the  trunk  and  limbs ;  and  I  have  seen  sweeps  so 
thickset  with  them,  that  a  hundred  or  more  might  have  been  counted. 

Such  are  some  of  the  numerous  morbid  states,  one  or  other  of  which 
may,  in  the  majority  of  cases,  be  assigned  as  predisposing  a  part  to  be- 
come the  seat  of  epithelial  cancer.  Expressions  are  sometimes  used, 
implying  that  the  part  does  not  become  the  seat  of  a  new  morbid  struc- 
ture, but  that  its  mode  of  action  is  changed,  or  that  the  change  is  only 
due  to  the  extension  and  deepening  of  a  common  epidermoid  or  warty 
growth.  The  truer  vieAV,  however,  may  be  expressed  by  saying  that 
the  part,  whatever  were  its  previous  state,  becomes  the  seat  of  epithe- 
lial cancer,  the  structures  of  which,  as  of  a  new  disease,  are  inserted 
among  the  original  or  previously  morbid  textures  of  the  part.  This 
evidently  happens  when  the  cancer  appears  in  parts  previously  healthy, 
or  in  the  deep-seated  tissues,  or  in  the  walls  of  ulcers,  or  in  a  pigmen- 
tary nsevus;  for,  in  these  cases,  no  morbid  structures  like  those  of  the 
epithelial  cancer  existed  previous  to  its  access.  Th&re  is  more  appear- 
ance of  similarity  and  continuity  of  disease  between  the  epithelial  can- 


630  EPITHELIAL    CANCEE. 

cers  and  the  warty  growths  by  which  they  are  sometimes  preceded ;  for 
here  both  the  earlier  and  the  later  disease  may  have,  in  common,  an 
accumulation  of  epidermoid  cells  and  an  enlargement  of  papillge.  Yet 
the  warts,  whether  incrusted,  or  others,  in  which  the  epidermoid  struc- 
tures are  only  superficial,  should  also,  I  think,  be  regarded  as  only  pre- 
disposing conditions  of  epithelial  cancer ;  as  diseased  parts,  not  cancer- 
ous, though  peculiarly  apt  to  become  the  seats  of  this  form  of  cancer. 
For  the  great  majority  of  these  are  stationary  affections,  or  may  disap- 
pear, or  be  cured,  even  in  cancerous  persons  ;  they  are  comparatively 
few  in  which,  after  a  certain  duration  as  simple  warts,  the  cancerous 
disease  is  manifested.  And  the  time  of  this  change  in  them  is  often 
well  marked.  Nearly  all  patients — even  those  who  can  assign  no  date 
to  the  beginning  of  the  wart  or  hardness,  or  other  previous  disease, — ■ 
can  refer  exactly  to  some  time  of  change  in  it,  when  it  began  to  "  grow 
up,"  or  "  be  sore,"  or  "  get  bad,"  discharge,  or  bleed.  They  thus  mark 
the  time  when  the  cancerous  mode  of  progress  was  commenced  ;  and 
from  this  time  the  history  of  all  such  cases  is  nearly  uniform — even  re- 
markably uniform,  if  it  be  compared  with  the  variety  of  the  histories  of 
the  previous  states. 

Now,  I  believe  that  this  change  in  the  life  of  the  warty  or  other  diseased 
part  is  always  associated  with  a  change  in  its  structure;  and  that  what- 
ever were  its  previous  state,  its  proper  tissue,  whether  papillge  or  any 
others,  now  become  the  seat  of  the  formation  of  epithelial  cancer-cells. 
It  is  hardly  possible  to  prove  such  a  change  of  structure  in  any  single 
case,  but  it  is  rendered  highly  probable  by  this, — that  in  those  warty 
structures  which  we  remove  because  experience  makes  us  believe  that 
they  are  in  progress  as  epithelial  cancers,  we  find  the  tissues  infiltrated 
with  the  specific  cancer-cells ;  while  in  those  which  have  been  long  sta- 
tionary, without  extension  or  outgrowth,  without  ulceration  or  ichorous 
discharge,  no  such  infiltration  is  found.  Certain  cases  must  be  ex- 
cepted from  this  statement  because  of  error  in  diagnosis.  I  have 
known  rodent  ulcers  excised,  in  the  belief  that  they  were  epithelial 
cancers ;  but  I  never  saw  any  growth  removed  as  an  epithelial  cancer, 
in  which  the  epidermoidal  cells  were  placed  only  on  the  surface  of  the 
vascular  tissues  ;  and,  on  the  other  hand,  I  have  never  seen  such  cells 
in  the  cutis  or  papillae  of  any  incrusted  or  other  wart,  in  which  the 
cancerous  mode  of  progress  was  not  yet  manifested.  The  opportunities 
of  examining  such  Avarts  as  observation  shows  to  be  most  apt  to  be 
precursors  of  epithelial  cancer  are  rare ;  but  I  have  examined  some  on 
the  scrotum,  and  one  on  a  lower  lip.  The  last  may  deserve  descrip- 
tion. 

A  healthy-looking  farmer,  QQ  years  old,  came  to  me  with  an  indura- 
tion, about  two  lines  wide  and  half  a  line  thick,  at  the  middle  of  the  florid 
margin  of  his  lower  lip.  The  indurated  part  was  slightly  sunken,  and 
covered  with  a  thin  yellow  scab.  This  disease  had  existed  two  years, 
frequently  scabbing  thickly,  then  desquamating,  never  soundly  healing; 


GROWTH    AND     ULCERATION.  631 

yet  it  had  made  no  progress.  I  removed  it,  chiefly  because  the  patient's 
father,  when  85  years  old,  had  had  cancer  of  the  lower  lip  ;  and  be- 
cause, if  not  already  cancerous,  this  could  not  but  be  thought  a  place 
very  likely  to  become  so.  I  found,  in  the  indurated  tissue,  inflamma- 
tory products  infiltrated  among  the  natural  structures  of  the  skin,  but 
no  appearance  of  epithelial  cancer-cells.  The  cutis  was  slightly  thick- 
ened ;  but  there  was  no  evidence  of  enlargement  of  papillae,  or  of  accu- 
mulated epidermis  ;  the  scab  seemed  formed  chiefly  of  dried  secretion. 

I  believe  that  such  a  description  as  this  would  apply  to  most  of  the 
warts  that  precede  epithelial  cancers  of  the  lower  lip,  and  that  we  may 
justly  say  of  them  that  they  are  not  cancerous,  but  are  such  parts  as, 
in  certain  persons,  are  peculiarly  apt  to  be  the  seats  of  cancer.  Why 
only  some  among  them  should  become  cancerous  we  can  no  more  ex- 
plain than  we  can  why,  among  so  many  injuries  inflicted,  so  few  should 
be  followed  by  erysipelas  or  tetanus  ;  or  why,  among  so  many  pigmen- 
tary moles  or  ngevi  as  may  be  found,  only  few  should  become  the  seats 
of  melanoid  cancer  ;  or,  in  a  yet  nearer  parallel,  why,  when  a  person 
has  many  such  moles,  the  melanoid  cancer  should  appear  in  only  one. 
In  these  varieties  of  fate,  there  is  nothing  unusual  in  Avarts,  if  we  re- 
gard them  as  only  predisposed  to  become  cancerous  ;  but,  if  we  regard 
them  as  the  first  stages  of  a  cancroid  or  cancerous  disease,  such  varie- 
ties of  progress  as  they  manifest  would  be  without  parallel. 

(e)  The  general  health  of  patients  with  epithelial  cancer  is  usually 
good,  till  it  is  affected  by  the  consequences  of  the  local  disease.  Less 
than  ten  per  cent,  of  them  appear  ill  at  their  first  observation  of  the 
disease.  No  primary  cachexia  can  be  observed  preceding  the  appear- 
ance of  the  growth  ;  nor  does  a  secondary  cachexia  ensue  earlier  than 
it  probably  would  in  any  disease  of  equal  duration  and  severity. 

When  the  formation  of  an  epithelial  cancer  has  once  commenced,  its 
natural  course  is  as  regularly  progressive  to  the  destruction  of  life,  as 
that  of  either  a  scirrhous  or  a  medullary  cancer.  Only,  the  rate,  and 
some  parts  of  the  method,  of  progress  are  different. 

The  average  rate  of  increase  of  epithelial  cancers  is  less  than  of 
either  of  the  other  kinds.  It  is  not  apt  to  be  arrested  altogether  ;  yet 
it  is  sometimes  so  slow  that,  in  a  year,  the  cancer  may  gain  only  a  line 
or  two  in  any  of  its  dimensions.  In  other  cases,  however,  and  espe- 
cially when  such  a  cancer  has  been  violently  injured,  the  progress  is 
much  more  rapid.  I  have  known  three-fourths  of  the  scrotum  covered 
with  ulcerating  soot-cancer,  and  part  of  the  urethra  surrounded  by  it, 
in  three  months  after  a  laceration  received  while  in  apparent  health ; 
in  another  case,  a  spheroidal  mass  of  soft  epithelial  cancer,  an  inch  in 
diameter,  formed  in  the  substance  of  the  cheek  in  two  months  ;  in  an- 
other, a  growth  more  than  an  inch  in  diameter  formed  in  ten  weeks  ; 
in  another,  the  whole  depth  of  the  lower  lip,  and  two-thirds  of  its  width, 
were  occupied  with  epithelial  cancer,  in  three  months  after  a  blow  on 


632  EPITHELIAL    CANCEE. 

a  little  cancer  at  its  margin  ;  in  another,  within  twelve  months,  the 
eyelids  and  a  large  part  of  the  contents  of  the  orbit  were  destroyed  by 
ulceration,  and  tuberous  masses,  from  one  to  three-quarters  of  an  inch 
in  diameter,  were  formed  under  the  integuments  of  the  brow,  the  temple, 
and  the  other  boundaries  of  the  orbit. 

Cases  such  as  these,  and  they  are  not  rare,  may  prove  the  error  of 
regarding  epithelial  cancer  as  a  trivial  or  an  inactive  disease  in  com- 
parison with  the  other  forms.  Its  rate  of  progress  is,  like  that  of  scir- 
rhous cancer,  widely  various  in  different  cases ;  it  has  its  acute  and  its 
chronic  instances.  Of  its  modes  of  growth,  and  of  ulceration,  and  of 
the  usual  coincidence  of  these  processes,  I  have  spoken  fully  in  the  for- 
mer part  of  the  lecture  (p.  608) ;  I  will  here  only  add  that  the  ulcera- 
tion, at  whatever  rate,  seems  constantly  progressive.  Some  portions 
of  the  ulcer  may  appear,  for  a  time,  as  if  skinning  over,  or,  portions 
of  the  disease  may  slough  away,  and  the  surfaces  they  leave  may  par- 
tially heal ;  but  I  do  not  remember  to  have  seen  any  process  of  healing 
or  wasting  so  nearly  accomplished  in  an  epithelial  cancer,  as  I  have 
described  in  some  cases  of  both  scirrhous  and  medullary  cancer,  in  the 
former  lectures  (pp.  550,  590). 

The  progress  of  the  ulceration,  and  the  coincident  deepening  of  the 
growth,  are  usually  attended  with  great  pain, — hot,  scalding,  and  widely 
diffusing  pain ;  or  with  pain  like  that  of  neuralgia  darting  in  the  course 
of  nerves.  With  this,  and  the  constant  ichorous  discharge  from  the 
ulcer,  and  the  occasional  bleedings  from  ulcerated  bloodvessels,  the  pa- 
tient becomes  cachectic ;  yet  probably  not  sooner  than  in  other  diseases 
of  equal  extent,  nor  in  any  very  characteristic  manner. 

Primary  epithelial  cancers  are  usually  single.  Two  growths  may 
sometimes  appear  at  once  in  the  same  region,  as,  e.  g.,  on  the  prepuce 
and  glans,  or  on  the  scrotum :  I  have  also  seen  instances  of  simultane- 
ous growth  in  the  eyelid  and  rectum  :  the  finger  and  rectum  :  and  the 
lip  and  scrotum  ;  but  such  events  are  so  rare,  that  they  may  probably 
be  called  accidental.  In  the  later  progress  of  the  disease,  separate 
masses  of  epithelial  cancer  may  be  sometimes  found  in  the  tissues,  or 
cancerous  warty  growths  on  the  surface,  around  the  primary  growth  or 
ulcer.  Healthy  tissue  appears  to  intervene  between  these  secondary 
cancers  and  the  primary  one :  and  they  may  be  compared  with  the  tu- 
bercles so  often  grouped  around  a  scirrhous  mammary  gland. 

The  lymphatic  glands,  sooner  or  later  in  the  progress  of  the  disease, 
usually  become  cancerous.  I  have  already  (p.  616)  described  the  man- 
ner of  their  infection.  I  feel  almost  disposed  to  think  that  epithelial 
cancer  is  a  much  worse  disease  in  this  country  than  in  France  or  Den- 
mark, when  I  see  how  far  my  observations  on  the  affection  of  the  lym- 
phatics differ  from  those  of  Lebert  and  Hannover.     Lebert*  says  that 

*  Traits  Pratiqtie,  p.  619. 


MULTIPLICITY EXTENSION.  633 

he  has  found  the  lymphatic  glands  affected  with  "  cancroid"  three  times 
in  81  cases ;  and  of  these  81,  60  were  certainly  cases  of  epithelial  can- 
cer. Hannover*  has  even  less  frequently  seen  them  diseased.  Now,  in 
42  cases  of  epithelial  cancer  collected  in  the  ordinary  course  of  hospital 
and  private  practice,  and  including  many  in  the  early  as  well  as  in  the 
latest  stages  of  the  disease,  I  have  observed  the  lymphatics  cancerous 
twenty  times.  In  the  greater  part  of  these  cases  the  characteristic 
cancer-structures  were  found  in  the  glands  removed  during  life  or  after 
death :  in  the  rest,  their  existence  was  concluded,  with  scarcely  less 
certainty,  from  the  enlargement,  with  induration,  rapid  growth,  clus- 
tering, and  destructive  ulceration  of  the  glands.  It  need  not  be 
suspected  that  in  any  of  these  cases  the  glands  were  enlarged  merely 
through  "irritation:"  such  a  state  does,  indeed,  occur  with  epithelial 
as  with  scirrhous  cancer,  but  the  diagnosis  of  this  from  the  cancerous 
enlargement  is  seldom,  in  either  case,  difficult. 

I  do  not  suppose  that  the  proportion  cited  above  expresses  the 
greatest  frequency  of  epithelial  cancer  in  the  lymphatic  glands.  I 
believe  rather,  that  very  few  cases  reach  their  natural  end  without  in- 
fection of  the  glands.  Even  after  the  primary  disease  has  been  wholly 
removed,  and  when  the  glands  at  the  time  of  the  operation  appeared 
healthy,  they  are  frequently,  and  often  alone,  the  seats  of  recurrences 
of  the  disease.  Sometimes,  also,  as  with  scirrhous  cancers  (p.  534),  we 
find  the  disease  in  the  lymphatics  greatly  preponderating  over  that  in 
the  primary  seat. 

My  observations  are  scarcely  less  different  from  those  of  Lebert,  in 
relation  to  the  occurrence  of  secondary  epithelial  cancers  in  internal 
organs.  In  eighteen  autopsies  (some  of  which,  however,  were  made  in 
fatal  cases  of  rodent  ulcer)  he  has  not  once  found  "  cancroid  growths" 
in  any  internal  part.  In  seven  autopsies,f  I  have  found  epithelial  can- 
cer once  in  the  heart,  and  once  in  the  lungs :  (its  appearance  in  these 
parts  is  described  at  pp.  618,  619.)  Doubtless,  the  internal  organs  are 
more  rarely  infected  than  in  any  other  form  of  cancer ;  but  they  do  not 
enjoy  an  absolute  immunity  ;  the  difference  between  the  epithelial  and 
the  other  cancers  is,  in  this  point  again,  one  of  degree,  not  of  kind. 

It  is  a  peculiarity  of  epithelial  cancers,  that  in  nearly  all  the  character- 
istics of  malignant  disease, — whether  the  propagation  to  the  lymphatics 
or  other  organs,  the  extension  to  deep-seated  parts,  the  recurrence  after 

*  Das  Epithelioma,  p.  24. 

■f  In  two  of  these  the  disease  had  not  reached  its  natural  end;  for  the  patients  died  in 
consequence  of  amputation.  In  another  case  I  found  epithelial  cancer  of  the  tor-.^ue,  with 
medullary  cancer  of  the  cervical  glands,  and  of  the  lungs;  but,  as  I  have  already  said  (p. 
617),  though  no  medullary  cancer-structures  were  found  in  the  primary  disease,  it  was  im- 
possible to  prove  that  they  had  never  existed,  for  a  large  portion  of  the  tongue  had  sloughed, 
before  death.  Virchow's  observations  on  the  occurrence  of  secondary  epithelial  cancer  in 
internal  organs  are  very  clear. 

41 


634 


EPITHELIAL    CANCER. 


removal,  or  the  rate  of  progress  towards  death, — greater  differences  are 
noted  according  to  the  seat  of  disease  than  among  the  medullary  can- 
cers of  different  parts.  The  anatomical  characters  of  the  disease  are 
in  all  parts  essentially  the  same,  but  their  history,  in  all  the  particulars 
noted  above,  differs,  so  as  to  justify  the  expression  that  the  disease  is 
less  malignant  in  some  parts  than  in  others.  It  is,  generally,  most  ma- 
lignant in  the  tongue,  the  interior  of  the  mouth,  and  the  penis  ;  least  in 
the  lower  extremities  and  the  scrotum ;  in  general,  also,  the  epithelial 
cancers  that  are  deep-seated  are  more  malignant  than  the  superficial. 

These  diversities  make  it  very  difficult  to  assign  the  average  duration 
of  life  in  persons  with  epithelial  cancer ;  and  the  difficulty  is  greatly 
increased  by  the  recorded  cases  being  often  mixed  or  confounded  with 
those  of  other  cancers  and  of  rodent  ulcers.  Taking  cases  with  clear  di- 
agnosis, without  regard  to  the  parts  affected,  the  average  duration  of 
life  in  twenty-three  cases  which  ran  their  natural  course  was  27.4 
months ;  and  in  thirty-five  cases  in  which  the  disease  was  once  or  more 
removed  by  operation,  57.6  months. 

The  following  table  will  show  the  durations  of  life  in  the  cases,  and 
may  be  compared  with  those  on  p.  555,  and  p.  593,  from  which  the  fore- 
going statement  was  derived : 


Duration  of  Life. 

Less  than  6 

mon 

ihs, 

Between 

6 

and 

12  months, 

" 

12 

18       " 

'■ 

IS 

24       " 

" 

24 

36       " 

" 

3 

4  years, 

" 

4 

" 

6       " 

" 

6 

" 

8       " 

More  than  8  years,  . 


Number  of  ( 
With  Operation. 
0 

^ases. 
Without 

1 

1 

6 

5 

6 

4 

1 

3 

4 

4 

3 

8 

0 

1 

0 

9 

2 

35 


23 


The  chief  point  which  this  table  shows,  in  contrast  with  those  of  other 
cancers,  is  in  the  larger  proportion  of  patients  living  more  than  four 
years.  Great  differences,  however,  as  to  length  of  life,  may  be  noted 
among  the  epithelial  cancers  of  different  organs.  Those  in  the  tongue 
rarely  survive  more  than  four  years ;  those  in  the  trunk  or  limbs  rarely 
destroy  life  in  less  than  three  years  :  a  majority  of  those  in  the  lower 
lip  survive  that  period.  The  age  at  which  the  disease  commences  has 
no  great  influence  on  its  duration.  The  average  duration  among  four- 
teen patients,  in  whom  it  commenced  at  or  below  45  years  of  age,  was 
39  months  ;  that  among  seventeen,  in  whom  it  commenced  later,  was 
45J  months ;  and  the  general  average  duration  was  not  exceeded  in 
the  first  list  more  often  than  in  the  second. 

A  considerable  prolongation  of  life  would  appear,  by  the  cases  I  have 
collected,  to  be  obtained  by  the  removal  of  epithelial  cancers.  The 
average  advantage,  as  shown  by  the  foregoing  table,  is  30  months  ;  and 


COURSE    AND    DURATION    OF    LIFE.  635 

although  this  great  cliiFerence  may  be  ascribed  to  a  careful  selection  of 
cases,  yet  the  average  is  sometimes  greatly  surpassed.  I  have  seen  a 
man  whose  leg  was  amputated  twenty  years  previously  for  epithelial 
cancer,  commencing  in  or  beneath  a  scar,  and  he  was  still  well.  A 
sweep  was  some  time  back  in  St.  Bartholomew's  with  a  small  scrotal 
cancer,  from  whom  one  of  the  same  kind  was  excised  thirty  years  pre- 
viously. Of  another,  Mr.  Curling*  gives  a  history  extending  over 
twenty-two  years,  and  including  five  operations.  A  man  from  whom 
Mr.  Lawrence  removed  a  cancer  of  the  lip  remained  well  for  nine  years, 
and  then  the  disease  appeared  in  the  lymphatic  glands. 

Cases  such  as  these  must,  however,  be  considered  very  rare.  Too 
much  regard  to  them,  and  the  confusion  of  the  rodent  ulcers  with  the 
epithelial  cancers,  have  led  to  a  common  belief  that  recovery  or  long 
life  may  be  promised  as  the  consequence  of  operations.  Such  a  promise 
will  not  prove  true  :  and  yet,  as  a  general  rule,  the  operation  is  to  be 
advised,  whenever  the  whole  of  the  disease  can  be  removed  without 
great  risk  of  life,  or  of  producing  worse  deformity  than  already  exists. 

For  (1)  though  the  instances  of  operations  followed  by  long  immunity 
from  the  disease  are  very  rare,  yet,  in  certain  cases,  these  results  may 
be  hoped  for.  This  is  especially  the  case,  I  think,  with  the  epithelial 
cancers  of  the  lower  extremity,  which  follow  injury,  and  for  wdiich  am- 
putation is  performed  ;  with  the  more  superficial  cancers  of  the  lip  ;  and, 
most  of  all,  with  the  soot-cancers  which  are  not  making  quick  progress. 
On  the  other  side,  according  to  present  experience,  such  lengthening 
of  life  can  rarely  be  hoped  for  after  operations  for  the  epithelial  can- 
cers of  the  tongue,  the  gums,  or  other  parts  in  the  interior  of  the 
mouth.  The  best  instance  of  these  that  I  have  yet  known,  is  one  of  a 
removal  of  an  epithelial  cancer  of  the  tongue,  in  which  eight  years 
elapsed  before  the  recurrence. 

(2)  In  the  majority  of  cases,  and  even  when  very  little  increase  of 
life  can  be  hoped  for,  the  removal  of  the  disease  may  give  great  comfort 
for  a  time.  In  general,  also,  the  greater  part  of  the  time  that  inter- 
venes between  the  recovery  from  the  operation  and  the  recurrence  of 
the  disease  may  be  reckoned  as  so  much  added  to  life  ;  for  although  we 
cannot  deny  a  diathesis,  or  specific  constitutional  affection,  in  epithelial 
cancers,  yet  it  is  by  the  progress  and  consequences  of  the  local  disease 
that,  in  the  majority  of  cases,  the  time  of  death  is  determined  ;  so  that, 
while  local  disease  is  absent,  life  may  be  shortening  at  scarcely  more 
than  the  ordinary  rate.  Of  course,  in  applying  such  a  rule  as  this 
may  suggest  in  practice,  we  must  except  from  it  certain  cases  in  which 
the  general  health  is  already  very  deeply  affected,  or  in  which  the  opera- 
tion would  be  perilously  extensive. 

(3)  The  extension  of  the  epithelial  cancer  to  the  lymphatic  glands  is 
not  an  insuperable  objection  to  operations.     The  disease  usually  re- 

*  On  Diseases  of  the  Testis,  p.  535. 


636  EPITHELIAL     CANCEK. 

mains  long  limited  to  the  glands  which  are  nearest  to  its  primary  seat 
(p.  616) ;  its  complete  removal  can  therefore  be  usually  accomplished  ; 
and,  although  I  can  cite  no  instance  of  very  long  survival  after  opera- 
tion including  cancerous  glands,  yet,  on  the  other  side,  I  can  cite  none 
which  would  prove  that  the  recurrent  disease  is  quicker  or  more  severe 
after  such  operations,  than  it  is  after  those  of  equal  extent  in  which 
the  glands  are  not  yet  diseased. 

(4)  The  general  rule  concerning  operations  in  cases  of  recurrent 
epithelial  cancer  may  be  the  same,  I  think,  as  for  the  primary  disease. 
A  second  operation  is,  in  general,  less  hopeful  than  a  first,  yet  not 
always  so ;  for  although  the  epithelial,  like  other  cancers,  usually  make 
progress  at  an  accelerating  rate,  yet  cases  are  not  wanting  in  which  the 
intervals  between  successive  operations  have  progressively  increased. 

(5)  The  recurrence  of  epithelial  cancer  after  operation  is  in  some 
cases  very  rapid,  in  others  greatly  retarded.  The  number  of  cases  in 
which  recurrence  ensues  at  a  medium  period  appears  comparatively 
small.  I  cannot  explain  the  fact,  if  it  be  one,  but  I  believe  that  if, 
after  operation,  a  patient  remain  free  for  eighteen  months,  it  is  very 
probable  that  the  immunity  will  continue  for  at  least  five  years. 

Let  me  now  collect  from  the  facts  of  this  lecture  the  grounds  which 
seem  to  justify  the  inclusion  of  this  disease  under  the  name  of  cancer. 
It  is  not  unimportant  to  do  so ;  for  we  may  be  certain  that,  in  this  case, 
the  name  of  the  disease  will  often  guide  the  further  study  and  the  treat- 
ment of  it. 

I  have  excluded  from  the  group  of  epithelial  cancers  the  rodent  ulcers, 
which  M.  Lebert  includes  with  them  under  the  name  of  "cancroid." 
The  two  diseases  are  so  constantly  unlike,  in  both  structure  and  history 
(see  p.  621),  that  their  separation  under  different  titles  seems  consistent 
with  the  most  usual  rules  of  nosology.  I  have  also  excluded  those  pa- 
pillary and  other  affections  of  the  skin,  in  which  epidermoid  structures 
are  accumulated  only  on  the  surface  of  the  affected  part.  For,  although 
these  may  sometimes  appear  like  the  first  stages  of  certain  epithelial 
cancers  (see  pp.  601  and  630),  yet  the  distinction  between  the  two  is 
commonly  well  marked  in  the  history  of  each  case ;  and,  in  their  re- 
spective anatomical  relations,  the  distinction  between  a  superficial  and 
an  interstitial  epidermoid  structure  is  very  significant ;  since  the  former 
has  its  nearest  homologue  in  natural  epithelia,  the  latter  in  cancerous 
infiltrations. 

Thus  limiting  the  diseases  to  be  included  under  it,  the  name  of  epi- 
thelial cancers  seems  justified  by  their  conformity  with  the  scirrhous 
and  medullary  cancers  in  these  following  respects  : 

(1)  The  interstitial  formation  of  structures  like  those  of  epithelium  is 
not  an  imitation  of  any  natural  tissue ;  it  constitutes  a  heterologous 
structure  ;  for  superficial  position  is  more  essential  to  the  type  of  epi- 
thelial structures,  than  any  shape  of  elemental  cells  or  scales  is. 


EPITHELIAL    CANCER.  637 

(2)  Even  that  delusive  appearance  of  homology,  which  exists  when 
the  structures  like  those  of  epithelium  are  formed  in  the  dermal  tissues, 
and  therefore  near  the  surface,  is  lost  in  nearly  all  the  cases  of  deep- 
seated  epithelial  cancers,  and  in  all  the  similar  affections  of  the  lym- 
phatic glands  and  internal  organs. 

(3)  The  interstitial  formation  of  cells  in  epithelial  cancer  is  conformed 
with  the  characteristic  plan  of  all  cancerous  infiltrations,  and  leads  to 
a  similar  substitution  of  new  structures  in  the  place  of  the  original  tis- 
sues of  the  aifected  part. 

(4)  The  interstitially  formed  cells  often  deviate  very  widely  from  the 
type  of  any  natural  epithelial  cell,  in  shape,  in  general  aspect,  in  method 
of  arrangement,  and  in  endogenous  formation  (p.  612,  e.  s.).  The  dif- 
ference between  them  and  any  natural  elemental  structures  is,  indeed, 
much  greater  than  that  between  many  medullary  and  scirrhous  cancer- 
cells,  and  the  cells  of  the  organ  in  which  they  grow:  e.  g.,  it  is  some- 
times difficult  to  distinguish  the  cells  of  a  medullary  cancer  in  the  liver 
from  those  of  the  liver  itself. 

(5)  The  pathology  of  epithelial  cancers  is  scarcely  less  conformed 
than  is  their  anatomy  to  the  type  represented  by  the  scirrhous  and  me- 
dullary cancers  ;  for,  not  only  are  they  prone  to  incurable  ulceration, 
and  to  repeated  and  often  very  rapid  recurrence  after  removal,  but 
(which  is  much  more  characteristic)  they  usually  lead  to  the  formation 
of  structures  like  themselves  in  the  lymphatic  glands  connected  with 
their  primary  seat;  they  lead  sometimes  to  similar  formations  in  more 
distant  organs  (p.  616,  e.  s.);  and  the  average  duration  of  life  in  pa- 
tients affected  with  them,  is,  on  the  whole,  not  greater  than  that  of 
those  who  have  scirrhous  cancer. 

(6)  In  their  growth,  and  in  their  recurrence,  there  is  no  tissue  which 
the  epithelial  cancers  do  not  invade  and  destroy  (pp.  604  and  609). 

(7)  A  peculiar  liability  to  them  exists  in  members  of  those  families 
in  which  scirrhous  or  medullary  cancer  also  occurs  (p.  626). 

Such  are  the  affinities  between  the  epithelial  and  (as  I  would  say)  the 
other  cancers.  They  are  so  numerous  and  so  close,  that  I  cannot  but 
think  we  should  be  guided  in  the  choice  of  a  name  by  them,  rather  than 
by  any  other  consideration.  They  are  surely  more  significant  of  affinity 
with  the  other  cancers  than  the  contrast  between  the  shapes  of  the  ele- 
mental cells  is  indicative  of  such  difference  as  should  be  expressed  by  a 
difi"erent  generic  name. 


638  MELANOID    AND    OTHER    CANCERS. 


LECTURE    XXXII  I. 

MBLANOID,    H^MATOID,    OSTEOID,    VILLOUS,    COLLOID,    AND    FIBROUS 

CANCERS. 

Of  the  three  chief  forms  of  cancer  which  I  have  now  described,  we 
may  observe,  I  think,  that  though  two  of  them  may  be  mixed  in  one 
mass,  or  may  occur  at  different  times  in  the  same  person,  or  in  different 
members  of  the  same  family,  and  though  there  are  forms  intermediate 
and  transitional  between  them,  yet  a  mass  of  one  of  them  does  not,  by 
any  transformation,  assume  the  characters  of  another.  A  scirrhous 
cancer,  I  think,  never  itself  becomes  medullary  or  epithelial ;  neither 
does  the  converse  happen ;  nor  do  we  see  any  indication  that  interfe- 
rence with  the  development  of  a  cancer  of  either  of  these  forms  would 
lead  it  into  the  assumption  of  the  characters  of  another.  Combination, 
coincidence,  succession,  or  interchange  of  these  three  forms  may  be 
found  ;  but,  I  believe,  no  transformation  of  a  growth  completed  or  in 
progress. 

If  this  be  true,  it  indicates  that  the  degree  of  difference  between  each 
two  of  these  three  forms  is  greater  than  that  which  exists  between  them 
and  the  cancers  to  which  I  shall  devote  this  lecture.  For  there  seems 
sufficient  reason  to  believe  that,  by  certain  generally  recognized  pro- 
cesses of  degeneration  or  disease,  a  medullary  or  epithelial  cancer  may 
become  melanoid,  or  haematoid ;  that  a  scirrhous  or  firm  medullary 
cancer  may  become  osteoid ;  that  the  colloid  character  may  be,  in  some 
measure,  assumed  by  either  of  the  three  chief  forms ;  and  that  either 
of  them  may  observe  the  villous  or  dendritic  mode  of  growth.  It  need 
not  always  be  supposed  that,  in  the  transformations  here  implied,  the 
cancer-structures  already  perfected  change  their  characters.  It  is  pro- 
bable, indeed,  that  such  changes  do  occur  in  some  of  the  instances  we 
have  to  consider ;  but,  in  others,  we  may  rather  believe  that  the  pecu- 
liarities of  structure  are  due  to  something  which  induces  degeneration 
or  disease  in  the  cancer-elements  in  their  most  rudimental  state. 

The  belief  that  the  six  forms  of  cancer,  whose  names  head  this  lec- 
ture, are  modifications  or  varieties  of  one  or  more  of  the  three  already 
described,  may  justify  my  describing  them  more  briefly,  and,  in  many 
parts,  by  terms  of  comparison  with  the  chief  forms.  Or,  if  this  belief 
be  not  a  good  reason  for  such  a  course,  it  must  be  sufficient,  that  the 
examples  of  all  these  six  forms  are  so  rare,  that  complete  and  indepen- 
dent histories  of  them  cannot,  at  present,  be  written. 

It  is,  I  think,  probable  that  other  groups  of  cancers  besides  these 
might  be  conveniently  described  as  varieties  of  the  principal  kinds  ;* 

*  This  may  be  the  case  with  what  Miiller  named  Carcinoma  fasciculatum  seu  hyalinum. 
But,  judging  from  his  description  and  Schuh's,  I  cannot  tell  whether  it  is  a  disease  which  I 
have  not  yet  seen,  or   whether  (as  I  am  more  inclined  to  believe)  the  name  has  not  been 


MELANOID     CANCER STRUCTURE. 


639 


but,  at  present,  it  seems  better  to  defer  the  introduction  of  new  names 
till  we  have  attained  more  accurate  knowledo;e. 


MELANOID    CANCER. 

The  Melanotic  or  Melanoid  Cancers  are,  with  very  rare  exceptions, 
medullary  cancers  modified  by  the  formation  of  black  pigment  in  their 
elemental  structures.  On  this  long-disputed  point  there  can,  I  think, 
be  no  reasonable  doubt.  I  have  referred  to  a  case  of  melanotic  epithe- 
lial cancer  (p.  616) :  but,  with  this  exception,  I  have  not  seen  or  read 
of  any  example  of  melanosis  or  melanotic  tumor  in  the  human  subject, 
which  might  not  be  regarded  as  a  medullary  cancer  with  black  pigment. 
In  the  horse  and  dog,  I  believe,  black  tumors  occur  which  have  no  can- 
cerous character  ;  but  none  such  are  recorded  in  human  pathology.  The 
conditions,  which  some  have  classed  under  the  name  "spurious  mela- 
nosis," are  blackenings  of  various  structures,  whose  only  common  cha- 
racter is  that  they  are  not  tumors. 

Melanotic  cancers  may  have  the  general  characters  of  any  of  the 
varieties  of  the  medullary  cancer  ;  but  the  primary  growths  are  rarely 
either  very  firm  or  very  soft.  They  may  appear  as  infiltrations ;  but 
are  more  often,  I  think,  separable  masses.  Their  characteristic  pigment 
marks  them  with  various  shades  of  iron-gray  or  brown,  deepening  into 
deepest  blackness.  The  pigment  is  variously  arranged  in  them.  Some- 
times, we  see,  on  the  cut  surface,  a  generally  diffused  brownish  tint, 
derived  from  thickly  sprinkled  minute  dots :  sometimes,  a  whole  mass 
is  uniformly  black :  sometimes,  one  or  more  deep  black  spots  appear  in 
the  midst  of  a  pure  white  brain-like  mass  : 
s"ometimes  (as  in  the  specimen  here  figured), 
in  half  a  tumor  there  are  various  shades  of 
brown  and  black,  in  the  other  half  the  same 
texture  uncolored :  sometimes  a  whole  mass 
is,  as  it  were,  delicately  painted  or  mapped,  as 
with  Chinese  ink.  There  are  thus  to  be  found, 
in  melanoid  cancers,  all  plans  and  all  degrees  of 
blackening  ;  and  these  diversities  may  be  seen 
even  in  different  parts  of  the  same  tumor,  or 
in  different  tumors  in  the  same  person. f  Nay, 
even  in  cancers  that  look  colorless  to  the  naked 
eye,  I  have  found,  with  the  microscope,  single 
cells  or  nuclei  having  the  true  melanotic  cha- 
racters. And  both  the  general  and  the  mi- 
croscopic aspect  of  the   disease  may  be  yet 

applied  to  some  specimens  of  the  soft,  flickering,  mammary  or  parotid  glandular  tumors,  or 
to  the  mammary  proliferous  cysts  that  are  prone  to  recur  (see  pp.  386,  487). 

*  Fig.  106.  Section  of  a  variously  shaded  melanoid  cancer  formed  beneath  a  mole  or 
pigmentary  nsevus.     Museum  of  St.  Bartholomew's.     Natural  size. 

f  All  these  varieties  are  illustrated  in  the  Museums  of  the  College  and  St.  Bartholomew's, 
by  specimens  referred  to  in  the  Indices  of  the  Catalogues,  vol.  i,  p.  133,  and  vol.  i,  p.  14. 


Fig.  106.* 


640 


MELANOID     CANCER. 


further  diversified  by  the  coincidence  of  degenerations  or  hemorrhages, 
producing,  in  the  unblackened  parts  of  the  tumors,  various  shades  of 
yellow,  or  of  blood-color. 

In  the  dark  turbid  creamy  or  pasty  fluid  that  may  be  pressed  from 
melanotic  cancers,  the  greater  part  of  the  microscopic  structures  are 
such  as  might  belong  to  an  uncolored  medullary  cancer.  It  is  often 
remarkable  by  how  small  a  proportion  of  pigment  the  deepest  black 
color  may  be  given  to  the  mass  :  a  hundredth  part  of  the  constituent 
structures  may  suffice.  The  pigment  is  generally  in  granules  or  mole- 
cules :  but  it  is  sometimes  in  nuclei  or  in  corpuscles  like  them. 

The  majority  of  the  pigment-granules  are  minute  particles,  not  much 
unlike  those  of  the  pigment-cells  of  the  choroid  membrane.  When  out 
of  focus,  they  appear  black  or  deep  brown ;  but,  when  in  focus,  they 
have  pellucid  centres,  with  broad  black  borders.  They  appear  spheri- 
cal ;  and  usually  the  majority  of  them  are  free,  i.  e.,  not  inclosed  in 
cells,  and  vibrate  with  molecular  movement  in  the  fluid  that  suspends 
them.  The  greater  part  of  the.  color  depends  on  these  free  granules 
(Fig.  107) ;  but  others  like  them  are  inclosed  in  the  cancer-cells,  or, 

Fig.  107.* 


more  rarely,  in  nuclei.  Sometimes  those  in  the  cells  are  clustered 
around  the  nucleus  ;  sometimes  they  are  irregularly  scattered  ;  in  either 
case,  they  appear  as  if  gradually  increasing  till  they  fill  the  cell,  and 
change  it  into  a  granule-mass,  which,  but  for  its  color,  we  might  exactly 
compare  with  the  granule-masses  of  fatty  degeneration.  While  the 
pigment-granules  are  thus  collecting,  the  nucleus  remains  clear  ;  but  at 
last,  when  the  cell  appears  like  a  granule-mass,  it  is  lost  sight  of. 
After  this,  moreover,  the  masses  formed  of  pigment-granules  may 
break  up,  and  add  their  granules  to  those  which  we  may  suppose  to 
have  been  free  from  their  first  formation.  The  completely  melanotic 
cells  and  their  corpuscles,  seen  singly  in  the  microscope,  look  not  black, 
but  rusty  brown  or  pale  umber-brown  :  like  blood-cells,  it  is  only  when 
amassed  that  they  give  the  full  tint  of  color. 

With  the  melanotic  granules,  there  is  sometimes  a  much  smaller 
number  of  particles  of  the  same  color,  and  the  same  apparently  simple 
structure,  but  of   larger  size:  from  -^-Q^jyth.  to  so'^otb  of   an  inch  in 


*  Fig.  107. 
350  times. 


Elemental  structures  of  melanoid  cancer,  referred  to  in  the  text.     Magnified 


PATHOLOGY.  641 

diameter.  These  may  be  both  free  and  in  cells ;  in  the  latter  case, 
lying  mingled  with  melanotic  granules  in  the  contents  of  the  cell. 
More  rarely,  corpuscles  like  the  nuclei  of  cancer-cells,  preserving  their 
shape,  size,  and  apparent  texture,  present  the  characteristic  brown  tint. 
Such  corpuscles  may  be  free ;  but  they  may  also  occupy  the  place  of 
nuclei  in  cells,  whose  other  contents  are  either  uncolored  or  mixed  with 
pigment-granules :  and  more  rarely,  a  single  corpuscle  of  the  same 
kind  may  be  seen  in  a  cell  containing  an  ordinary  colorless  nucleus. 

In  all  the  main  facts  of  their  pathological  history,  the  melanotic  can- 
cers are  in  close  conformity  with  the  medullary :  and  this  may  be 
reckoned  among  the  evidences  that  there  is  much  less  diflFerence  be- 
tween these  two  forms  than  there  is  between  the  medullary  cancers  and 
either  the  scirrhous  or  the  epithelial. 

In  the  tables  of  365  cases  of  cancer  from  which  those  in  the  foregoing 
lectures  were  derived,  there  are  25  cases  of  melanoid  cancer.  Seven- 
teen of  the  patients  were  females,  8  were  males.  In  14  cases,  the 
primary  seat  of  the  disease  was  in  the  skin  or  subcutaneous  tissue ; 
in  9,  in  the  eye  or  orbit;  in  1,  in  the  testicle;  in  1,  in  the  vagina.* 
In  this  limitation  to  a  few  primary  seats,  and  in  its  proneness 
to  affect  certain  abnormal  parts  of  the  skin,  are  the  chief  peculiari- 
ties of  this  variety  of  cancer  ;  but  on  the  other  points  which  may  be 
settled  by  counting,  I  might  have  added  the  25  cases  to  those  of  ordi- 
nary medullary  cancer,  without  disturbing  the  results  stated  in  Lecture 
XXXI. 

Thus,  the  ages  of  the  patients  at  the  access  of  the  cancer  were  as 
follow : 


Under 

10 

years, 

.   2 

Between  10  and  20 

.   1 

" 

20  "  30 

7 

" 

30'  "  40 

.   4 

" 

40  "  50 

.   5 

a 

50  "  60 

.   4 

Above 

60 

.   2 

The  only  notable  difference  in  this  table,  when  compared  with  that 
at  page  582,  is  in  the  inferior  proportion  of  cases  before  20  years  of 
age  ;  a  difference  mainly  determined  by  the  large  number  of  cases  of 
uncolored  medullary  cancer  of  the  eye  in  children, f 

Among  10  patients  with  melanoid  cancer,  one  had  had  a  relative  who 
died  with  cancer  of  the  breast ;  another  had  many  relatives  with  pig- 
mentary nsevi  like  that  in  which  her  own  cancer  originated.  In  another 
group  of  10  cases  3  had  had  cancerous  relatives. 

*  I  once  saw  primary  melanotic  cancer  of  the  liver;  but  I  have  no  complete  record  of  the 
case. 

t  This  fact  is  corroborated  by  one  of  the  tables  in  Mr.  Pemberton"s  "  Observations  on 
Melanosis,"  1857,  p.    18;  an   essay  containing  the  results  of  the  records  of  sixty  cases  of 

melanosis. 


642  MELANOID    CANCER. 

In  20  pf  the  cases,  the  previous  history  of  the  affected  part  is  re- 
corded. In  3  of  those  in  which  the  eye  was  affected  it  had  been  mor- 
bidly changed  by  previous  inflammatory  disease ;  in  2  it  had  appeared 
healthy.  Among  the  14  cases  affecting  the  skin  or  subcutaneous  tissue, 
one  patient  assigned  no  local  cause  ;  2  referred  to  injury,  and  were  un- 
certain of  the  previous  condition  of  the  skin ;  in  10  the  disease  com- 
menced beneath  a  congenital  pigmentary  ngevus,  or  dark  mole  ;  and 
in  1,  in  what  the  patient  called  a  wart  of  several  years'  standing.*  I 
shall  presently  revert  to  these  facts. 

In  regard  to  their  rate  and  method  of  growth,  their  ulceration,  and 
their  multiplying  in  parts  near  and  distant  from  their  primary  seat,  I 
believe  the  general  history  of  the  melanotic  cancers  is  parallel  with  that 
of  the  medullary  given  in  a  former  lecture  (p.  585,  e.  s.).  But  they 
present  even  a  greater  tendency  to  multiply  in  the  subcutaneous  tissue, 
growing  here  in  vast  numbers  of  small  soft  tubercles. 

In  like  manner,  the  duration  of  life  in  melanotic  nearly  corresponds 
with  that  in  medullary  cancers..  In  18  cases,  in  all  of  which  the  pri- 
mary disease  was  removed  (but  in  two  only  partially),  the  durations  of 
life  from  the  first  notice  of  the  cancer  were  as  follow  (and  the  table  may 
be  compared  with  that  on  p.  594) : 

Between    6  and  12  months  in  3  cases. 

"  12    "     18  "         4      " 

24    "     36  "         5       " 

36     "     48  "  1       " 

Above      48  "         5      " 

Among  18  cases,  whose  history  is  known  for  some  time  after  the  re- 
moval of  the  primary  disease,  one  has  survived  for  three  years,  another 
for  ten  months,  without  recurrence  of  the  disease.  In  the  rest  the  dis- 
ease recurred  at  the  following  periods  (compare  p.  594)  : 

Between     ]  and     3  months  in  7  cases. 

I  "  3    "6  "4      " 

"  6    "     12  "         2       " 

•       "  12    "     24  "         2      " 

24    "     36  "  1       ■■■ 

Seeing  this  close  correspondence  in  their  general  pathology,  the  rules 
respecting  operations  for  melanoid  cancers  must  be  the  same  as  for  the 
medullary.     (See  p.  595.) 

I  have  reserved  for  separate  consideration  some  of  the  peculiarities 
of  melanoid  cancers.  Three  things  in  them  especially  deserve  reflec- 
tion, namely  :  (1)  their  color  ;  (2)  their  proneness  to  take  their  first  seat 
in  or  near  cutaneous  moles  ;  (3)  their  profuse  multiplication. 

1.  The  color  of  the  melanoid  cancers  is  due  to  a  pigment-formation, 

*  Of  Mr.  Pemberton's  34  cases  of  melanosis  of  the  skin,  15  commenced  "in  or  near  a 
congenital  mole,  wart,  or  mark." 


PATHOLOGY.  643 

corresponding  with  that  which  we  find,  in  the  normal  state,  in  the  pio^- 
ment-cells  of  the  choroid  membrane,  and  in  the  rete  mucosnm  of  colored 
skins.  Their  usual  primary  occurrence  near  these  seats  of  natural 
pigments  may,  therefore,  be  regarded  as  an  illustration  of  the  tendency 
of  cancers  to  conformity,  at  least  sometimes  and  in  some  respects,  with 
the  characters  of  the  adjacent  natural  textures. 

But  another  meaning  of  the  pigment  in  melanotic  cancers  is  suggested 
by  its  likeness  to  that  which  accumulates  in  the  lungs  and  bronchial 
glands  in  advancing  years,  and  in  the  darkening  cuticle  of  many  old 
persons.  The  coloring  particles  are  probably  different  in  these  cases ; 
they  produce  different  shades  or  tinges  of  blackness,  but  their  plans  of 
formation  and  arrangement  are  in  all  similar.  And  the  analosv  of 
their  formation  in  the  aged,  and  in  some  other  instances  (p.  84),  may 
warrant  us  in  regarding  melanosis  as  a  pigmental  degeneration  of  me- 
dullary cancer.  The  chief  characters  of  its  minute  structures  agree 
with  this,  especially  the  gathering  of  pigment-molecules  about  the  nu- 
cleus, their  gradually  filling  the  cell-cavity,  till,  both  the  nucleus  and 
the  cell-wall  disappearing,  the  nucleated  cell  is  transformed  into  a  dark- 
colored  granule  mass.  In  all  these  characters  there  is  an  exact  parallel 
between  the  transformations  of  the  cells  in  melanoid  cancers  and  the 
usual  changes  of  the  fatty  degeneration.  (Compare  p.  528  and  p.  611.) 

2.  The  proneness  of  melanoid  cancers  to  grow  first  in  or  beneath  pig- 
mentary moles  is  very  evident ;  and  I  am  not  aware  that  such  moles  are 
peculiarly  apt  to  determine  the  locality  of  any  other  tumors ;  for,  ex- 
cept a  case  (p.  600)  in  which  an  epithelial  cancer  grew  from  one,  I 
have  met  with  no  instance  of  other  than  melanoid  cancers  connected 
with  them.* 

The  fact  is,  I  suppose,  quite  inexplicable ;  but  it  may  be  usefully 
suggestive.  It  seems  a  striking  illustration  of  the  weakness  in  resist- 
ing disease  which  belongs  to  parts  congenitally  abnormal.  It  seems, 
also,  to  be  an  evidence  that  a  part  may  very  long  remain  apt  for  the 
growth  of  cancer,  and  not  become  the  seat  of  such  a  growth,  till  the 
cancerous  diathesis,  the  constitutional  element  of  the  disease,  is  esta- 
blished. And  this  event  may  be  very  long  delayed :  as  in  a  woman,  80 
years  old,  whom  I  saw  with  a  large  melanotic  tumor,  which  had  lately 
grown  rapidly  under  a  mole  that  had  been  unchanging  through  her  long 
previous  life.  But  again,  this  peculiar  affinity  (if  it  may  be  so  called) 
of  moles  for  melanoid  cancers,  may  make  us  suspect  that  there  may  be 
other,  though  invisible,  defects  of  first  formation  in  our  organs,  which 
may  render  them,  or  even  small  portions  of  them,  peculiarly  apt  for 
the  seats  of  malignant  and  other  specific  diseases.  It  is  often  only  the 
color  that  makes  us  aware  of  the  peculiarity  of  that  piece  of  a  man's 

*  Pirogoff  (Klinische  Chirurgie,  H.  i,  p.  34)  relates  three  cases  of  removal  of  na-vi  (an- 
giektasie),  which  was  followed  by  growth  of  medullary  cancers,  at  or  near  the  seat  of  ope- 
ration. They  all  appear  to  have  been  medullary,  not  melanotic,  cancers;  but  the  third  case 
may  have  been  melanotic. 


644  MELANOID    CANCER. 

skin  in  whicli  cancer,  if  it  ever  occur  in  him,  will  be  most  likely  to 
grow  :  and  yet  color  is  so  unessential  a  condition  of  texture,  that  we 
may  well  believe  that  all  the  more  real  conditions  of  such  liability  to 
cancer  may  be  present  without  peculiarity  of  color,  though,  being  with- 
out it,  the  part  in  which  they  exist  may  not  be  discernible. 

I  have  spoken  of  the  pigmentary  moles  as  becoming  the  seats  of  me- 
lanotic cancers.  It  might  seem  as  if  the  mole  were,  in  some  sort,  the 
first  stage  of  the  cancer  ;  but  it  is  not  so :  the  structures  and  the  life  of 
the  mole  are  those  of  natural  skin  and  epidermis,  abnormal  in  quantity 
and  color,  but  in  no  more  essential  properties  :  there  are  no  structures 
in  moles  like  those  of  cancer  till,  at  a  certain  and  usually  notable  time, 
cancer  begins  to  be  formed  in  them.  And  here  let  it  be  observed,  how 
close  is  the  correspondence  in  these  respects  between  the  pigmentary 
moles,  and  the  warts  that  are  apt  to  become  the  seats  of  epithelial  can- 
cers (p.  628).  The  patient  is  usually  aware  of  the  time  at  which  a 
mole,  observed  as  an  unchanging  mark  from  birth  or  infancy,  began  to 
grow.  In  some  instances  the  growth  is  superficial,  and  the  dark  spot 
acquires  a  larger  area  and  appears  slightly  raised  by  some  growth  be- 
neath it :  in  other  cases  the  mole  rises  and  becomes  very  prominent  or 
nearly  pendulous.  I  believe  that  when  the  mole  becomes  thus  promi- 
nent, the  chief  seat  of  the  cancerous  formation  is  in  the  superficial  layer 
of  the  cutis  and  in  the  place  of  the  rete  mucosum ;  and  that  when  it 
only  extends  itself,  the  cancerous  growth  is  chiefly  in  the  skin  and  sub- 
cutaneous tissue.  In  the  former  case,  the  cancer-structures  are  usually 
infiltrated  among  the  natural  structures  of  the  affected  part ;  in  the 
latter,  they  generally  form  a  distinct  tumor,  w^iich  may  be  dissected 
from,  though  it  is  closely  connected  with  the  surrounding  tissues  and 
the  thinned  layer  of  cutis  and  dark  cuticle  that  covers  it.  (Fig.  106, 
p.  639.) 

The  general  characters  of  the  growths  thus  forming  correspond,  I 
believe,  in  every  respect  with  the  medullary  cancers  of  the  skin  and 
subcutaneous  tissue  (p.  579) :  color  alone  distinguishes  them  ;  they  are 
equally  prone  to  multiplicity.  Often  in  removing  a  deep-set  melanotic 
mass,  smaller  masses  are  found  imbedded  in  the  adjacent  fat  or  other 
tissue,  and  sometimes  the  formation  of  one  or  more  subcutaneous  growths 
almost  exactly  coincides  with  the  outgrowths  of  the  mole  and  its  occu- 
pation by  the  cancer-structures. 

3.  The  multiplicity  of  secondary  melanoid  formations  is  often  very 
striking.  I  have,  indeed,  seen  one  case  in  which,  to  the  last,  only  the 
lymphatic  glands  connected  with  the  primary  growth  were  diseased  ; 
and  another  in  which  only  the  liver  and  some  lymphatics  were  affected; 
but  the  more  frequent  issue  of  the  cases  almost  literally  justifies  the 
expression  that  the  disease  is  everywhere.  Are  we  to  conclude  from 
this  that  the  multiplication  of  melanoid  cancers  is  more  abundant  than 
that  of  the  medullary  cancers,  which  in  other  respects  they  so  closely 
resemble  ?    I  think  not.    We  can  easily  see  all  the  secondary  melanoid 


HiEMATOID    CANCER.  645 

formations,  even  the  smallest  and  least  aggregated ;  and  it  is  often  the 
color  alone  that  draws  attention  to  many  which,  but  for  it,  we  should 
not  have  noticed.  I  suspect  that  equally  numerous  formations  exist  in 
many  cases  of  medullary  cancers,  but  are  unseen,  being  uncolored. 

H^MATOID  CANCEE. 

This  name  may  perhaps  be  retained  to  express  a  form  of  cancer 
which  Mr.  Hey  had  chiefly  in  view  when  he  proposed  the  name  of  Fun- 
gus Hoematodes.*  It  is  most  probable  that  all  the  cases  to  which  he 
gave  this  name  were  soft  medullary  cancers;  and  his  attention  was 
especially  directed  to  the  fact  that  when  the  morbid  growth  protrudes 
through  the  skin,  the  protruding  portion  may  have  such  a  shape  as,  in 
the  conventional  language  of  surgery,  is  called  fungous,  and  often 
bleeds  largely,  and  is  so  vascular,  or  so  infiltrated  with  blood,  that  it 
looks  like  a  clot. 

The  identity  of  the  fungus  hsematodes  of  Hey  with  the  medullary 
cancers  was  fully  recognized  by  Mr.  Wardrop  and  others  ;  but  unfor- 
tunately, certain  foreign  writers,  regarding  the  hemorrhage  as  the  dis- 
tinctive character  of  the  disease,  included  under  the  same  term  nearly 
all  severely  bleeding  tumors,  of  whatever  kind.f  It  was  an  unhappy 
misuse  of  Hey's  name,  by  which  he  meant  to  express,  not  a  bleeding 
growth,  but  one  like  a  clot  of  blood :  and  it  led  to  a  confusion  which  is 
still  prevalent. 

Leaving  the  term  fungus  hsematodes,  we  may  employ  that  of  hsema- 
toid  cancer,  for  such  as  are  like  clots  of  blood  through  the  quantity  of 
blood  that  they  contain.  The  likeness  is  indeed,  I  believe,  only  an  acci- 
dental one,  due  to  hemorrhage  into  the  substance  of  the  cancer,  from  rup- 
ture of  some  of  its  thin-walled  bloodvessels.  It  seldom  exists  in  the  whole 
mass  of  a  cancer ;  but  usually,  while  some  parts  have  the  ordinary  as- 
pects of  medullary  or  some  other  form  of  cancer,  other  parts  are  blood- 
like.    The  best  illustration  of  the  disease  that  I  have  seen  is  in  a  laro-e 

o 

tumor,!  of  which  one-half  might  be  taken  as  a  good  type  of  the  brain- 
like medullary  cancer,  and  the  other  half  as  an  equally  good  type  of  the 
hsematoid.  This  half  had  been  deeply  punctured  during  life ;  it  had 
bled  very  freely,  and  the  simultaneous  bleeding  into  its  own  substance 
had,  doubtless,  changed  it  from  brain-like  to  blood-like. 

Probably  any  cancer  may  thus  be  made  hsematoid ;  but  the  change 

*  Observations  in  Surgery,  p.  239. 

f  Among  the  cases  thus  confused  are  some  strange  ones  of  profuse  bleedings  from  sup- 
pose(l  growths,  of  which  little  or  nothing  could  be  found  after  death.  Such  a  case  is  re- 
lated by  Mr.  Abernethy  (On  Tumors,  p.  127 — note)  ;  and  a  specimen  from  Mr.  Liston's 
Museum  is  in  the  Museum  of  the  College,  302  A.  It  is  perhaps  impossible  at  present  to 
say  what  these  diseases  were;  but  I  suspect  they  were  medullary  cancers  with  bloodves- 
sels excessively  developed,  like  those  of  an  erectile  tumor. 

X  Mus.  of  St.  Bartholomew's,  Ser.  xxxv.  No.  2&. 


64:6  OSTEOID     CANCER. 

is  peculiai'ly  apt  to  happen  in  those  which  are  of  the  softest  texture  and 
most  rapid  growth,  and  which  are  situated  where  they  are  least  sup- 
ported by  adjacent  parts. 

OSTEOID    CANCER. 

Miiller  assigned  the  name  of  osteoid  tumor,  or  ossifying  fungous 
growth,*  to  a  form  of  disease  of  which,  Avith  admirable  acumen,  he  col- 
lected several  cases  illustrating  these  as  its  distinctive  characters, — 
that  the  primary  tumor  consists  chiefly  of  bone,  but  has,  on  its  surface 
and  in  the  interstices  of  its  osseous  parts,  an  unossified  fibrous  consti- 
tuent as  firm  as  fibrous  cartilage  ;  and  that,  after  a  time,  similar  growths 
ensue  in  parts  distant  from  the  seat  of  the  first-formed,  and  not  on 
bones  alone,  but  in  the  areolar  tissue,  serous  membranes,  lungs,  lym- 
phatics, &c.  Mr.  Stanleyf  has  described  the  same  disease  under  the 
name  of  Malignant  Osseous  Tumor  ;  and  single  examples  of  it  may  be 
found  under  the  names  of  periosteal  exostosis,  fibrous  osteo-sarcoma, 
foliated  exostosis,  &c.  Miiller  was  disposed  to  call  it  osteoid  cancer; 
and  certainly  this  name  is  best  suited  to  it,  its  intimate  afiinity  with 
the  other  forms  of  cancer  being  evident  in  these  things, — (1)  its  corre- 
spondence, in  nearly  every  particular  of  structure  and  of  history,  with 
the  characters  of  cancerous  disease,  as  exemplified  in  the  scirrhous  and 
medullary  forms ;  (2)  its  not  unfrequent  coexistence  with  medullary 
cancer  of  the  ordinary  kind,  either  in  a  single  mass  of  tumor,  or  in 
different  tumors  in  the  same  person ;  (3)  the  uninterrupted  gradations 
between  it  and  the  scirrhous  and  medullary  cancers ;  (4)  its  mutations 
with  the  same,  in  hereditary  transmission  or  in  secondary  productions. 
I  cannot  doubt  the  propriety  of  calling  a  disease  cancer,  in  which  these 
facts  can  be  demonstrated  ;  and  I  believe  that  the  most  probable  view  of 
the  nature  of  osteoid  cancers  would  be  expressed  by  calling  them  ossified 
fibrous  or  medullary  cancers,  and  by  regarding  them  as  illustrating  a 
calcareous  or  osseous  degeneration.     (See  p.  540,  and  compare  p.  87.) 

The  primary  seat  of  osteoid  cancer  is  usually  some  bone ;  but  it  is 
not  limited  to  bones.  In  a  case  by  Pott,J  quoted  by  Miiller,  the  pri- 
mary tumor  lay  "  loose  between  the  sartorius  and  vastus  internus  mus- 
cles." In  the  Museum  of  St.  Thomas's  Hospital  there  is  a  tumor,  like 
an  osteoid  cancer,  which  was  removed  from  near  a  humerus,  and  another 
from  a  popliteal  space.  In  all  these  cases,  the  removal  of  the  tumor 
was  followed  by  the  growth  of  medullary  cancers  with  little  or  no  bone 
in  them'. 

Among  the  bones,  the  lower  part  of  the  femur  is,  with  remarkable 

*  Ueber  ossificirende  Schwamme,  oder  Osteoid-Geschwiilste  (Miiller's  Archiv,  1843, 
p.  396). 

■j-  On  Diseases  of  the  Bones,  p.  163. 

J  Works,  by  Earle,  iii,  313.  I  tliink  that  No.  24-29  A  in  the  College  Museum  may  be  re- 
garded as  an  osteoid  cancer  of  the  testicle,  thougli  the  bone-like  substance  has  not  the  cha- 
racters of  perfect  bone. 


STRUCTURE.  647 

predominance,  the  most  frequent  seat  of  osteoid  cancer.  Among  27 
cases,  of  which  I  have  seen  histories  or  specimens,  15  had  this  part  for 
their  seat :  the  skull,  tibia,  humerus,  ilium,  and  fibula,  were  each  af- 
fected in  two  cases,  and  the  ulna  and  metacarpus  each  in  one  case. 

In  most  cases,  the  osteoid  growth  occurs  coincidently  within  and  on 
the  exterior  of  the  bone,  following  herein  the  usual  rule  of  medullary 
cancers ;  but  it  may  exist  on  the  exterior  alone  :  and  I  have  twice  seen 
its  fibrous  basis  in  the  cancellous  tissue  of  a  bone,  of  which  the  exterior 
was  surrounded  with  soft  medullary  cancer. 

In  the  best  examples  of  osteoid  cancer,  i.  e.  in  those  in  which  its  pe- 
culiar characters  are  most  marked,  it  presents,  if  seated  on  a  long  bone, 
such  as  the  femur,  an  elongated  oval  form ;  if  on  a  flat  bone,  a  bicon- 
vex form.  Its  elongated  shape  on  the  femur,  the  swelling  gradually 
rising  as  we  trace  down  the  shaft,  and  then  rather  less  gradually  sub- 
siding at  the  borders  of  the  condyles,  is  almost  enough  for  a  diagnosis 
of  the  osteoid  cancer  from  other  hard  tumors.  It  is  like  the  enlarge- 
ment produced  by  simple  thickening  of  the  bone  or  periosteum  :  a  like- 
ness which  is  increased  by  the  smoothness  of  surface,  the  nearly  incom- 
pressible hardness,  and  the  considerable  pain,  which,  in  general,  all 
these  swellings  alike  present. 

When  we  dissect  down  to  an  osteoid  cancer  (taking  one  on  the  femur 
for  a  type)  we  usually  find  the  adjacent  tissues  healthy,  except  in  being 
stretched  around  the  swelling.  Small  masses  of  firm  cancer  may,  how- 
ever, be  imbedded  in  them,  distinct  from,  but  clustered  around,  the  chief 
mass.  The  periosteum  is  usually  continued  over  the  cancer,  but  scarcely 
separable  from  it.  The  surface  is  smooth,  or  very  lowly  and  broadly 
tuberous.  A  section  generally  shows  that  the  exterior  of  the  growth 
is  composed  of  a  very  firm,  but  not  osseous  substance ;  while  its  inte- 
rior part,  i.  e.  that  which  lies  nearest  to  the  shaft,  and  that  which  is  in 
the  place  of  the  cancellous  tissue,  is  partially  or  wholly  osseous.  The 
two  substances  are  closely  interblended  where  they  meet ;  and  their 
relative  proportions  differ  much  in  difi"erent  specimens,  according  to  the 
progress  already  made  by  ossification. 

The  unossified  part  of  the  tumor  is  usually  exceedingly  dense,  firm, 
and  tough,  and  may  be  incompressibly  hard ;  its  cut  surface  uprises 
like  that  of  an  intervertebral  fibrous  cartilage,  or  that  of  one  of  the 
toughest  fibrous  tumors  of  the  uterus.  It  is  pale,  grayish,  or  with  a 
slight  yellow  or  pink  tint,  marked  with  irregular  short  bars  of  a  clearer 
white ;  rarely  intersected  as  if  lobed,  but  sometimes  appearing  banded 
with  fibres  set  vertically  on  the  bone. 

The  bony  part  of  the  tumor,  when  cleared  by  maceration,  has  charac- 
ters altogether  peculiar  (Fig.  108).  In  the  central  parts  it  is  (in  the 
best-marked  specimens)  extremely  compact,  scarcely  showing  even  any 
pores,  white  and  dry.  To  cut,  it  is  nearly  as  hard  as  ivory,  yet,  like 
hard  chalk,  it  may  be  rubbed  or  scraped  into  fine  dry  powder.     At  its 


650  '  OSTEOID     CANCER. 

greater  differences  than  may  be  found  in  comparing  the  less  with  the 
more  firm  parts  of  a  single  primary  mass  of  the  disease. 

The  microscopic  characters  of  the  ossified  part  of  the  cancer  are  those 
of  true  bone,  but  rarely  of  well-formed  bone.  In  some  'parts — espe- 
cially in  the  secondary  cancers — that  which  appears  to  be  done  is  only 
an  amorphous  granular  deposit  of  lime-salts,  like  those  in  ordinary  cal- 
careous degenerations.  In  other  parts  the  lacunae  of  true  bone  are 
distinct,  but  they  are  small,  and  their  canalicules  are  few  and  short, 
and  without  order.  Haversian  canals  also  exist  with  these,  but  they 
have  not  a  large  series  of  concentric  lamellae  like  those  in  normal  bone. 
In  other  instances,  but  these  are  rare,  the  lacunae  are  more  nearly  per- 
fect; their  canalicules  communicate  with 'one  another,  and  with  the 
cavities  of  the  Haversian  canals.  The  bone  with  distinct  lacunae  and 
canalicules  is  not  found  exclusively  in  the  primary  cancer,  or  near  the 
natural  bone  on  which  it  is  seated  :  here,  indeed,  the  complete  bone  is 
most  frequent ;  but  it  may  be  found,  also,  in  the  secondary  growths  in 
the  glands  and  elsewhere.  Th^ese  differences  between  the  bone  of  the 
primary  and  that  of  the  secondary  osteoid  cancers,  like  the  similar 
differences  of  their  unossified  parts,  are  only  differences  of  degree,  such 
as  may  be  found  in  separate  parts  of  the  same  mass  ;  they  are,  probably, 
to  be  ascribed  only  to  more  recent  or  more  rapid  growth. 

The  foregoing  description  of  the  osteoid  cancers  may  suffice  to  show 
that  their  nearest  affinities,  judging  by  the  structure  of  their  unossified 
part,  are  to  the  fibrous  cancers,  of  which  I  spoke  at  p.  541,  and  to  the 
firmest  of  the  medullary  cancers  (p.  567).  When  abundant  cancer-cells 
are  present  they  most  nearly  resemble  the  latter  form  ;  when  they  are 
almost  wholly  fibrous,  the  former.*  Their  peculiarity,  as  cancers,  is  in 
their  ossification.  In  this  they  may  seem  to  approximate  to  the  non- 
cancerous tumors  :  but,  really,  they  remain,  even  when  ossified,  very 
distinct  from  any  of  them.  I  have  enumerated  (p.  483)  the  characters 
by  which  they  are  distinguished  from  both  the  hard  and  the  cancellous 
osseous  tumors  ;  and  the  difference  is  as  complete,  and,  I  believe,  as 
constant,  as  that  of  their  fibrous  basis  is  from  the  structure  of  any  non- 
cancerous fibrous  tumor. 

If  we  consider  only  their  osseous  part,  the  osteoid  cancers  most  nearly 
resemble  those  soft  medullary  cancers  which  have  the  most  abundant 
internal  skeletons.  There  is,  indeed,  no  absolute  line  of  distinction  to 
be  drawn  between  the  two.  It  may  be  very  evident,  in  the  typical 
specimens  of  each,  that  the  skeleton  of  the  soft  medullary  cancer  is 
formed  by  ossification  of  the  intersecting  and  overgrown  infiltrated 
periosteum  (p.  566) ;  and  that  the  bone  of  the  osteoid  cancer  is  formed 
by  ossification  of  the  proper  cancerous  substance ;  but,  between  these 

*  A  case  of  osteoid  cancer  is  minutely  related  by  Mr.  Sedgwick  (Br.  and  For.  Med.  Chir. 
Rev.,  July,  1855),  in  which  there  were  secondary  formations  in  the  clavicle,  thorax,  and  head, 
but  the  tumors  in  the  head  assumed  the  characters  of  ordinary  encephaloid,  which,  Mr. 
Sedgwick  thinks,  favors  the  opinion  expressed  in  the  text  of  the  relation  of  these  osteoid 
cancers  to  the  medullary  cancers. 


PATHOLOGY.  '  651 

extremes  or  types,  there  are  numerous  instances  in  which  the  two  con- 
ditions are  mingled,  or  through  which  the  one  condition  merges  into 
the  other.  And  this  is  no  more  than  we  might  expect,  seeing  the  fre- 
quency Avith  which  the  osteoid  and  the  medullary  disease  appear  to- 
gether, or  in  succession. 

The  materials  for  a  general  pathology  of  osteoid  cancers  are  very 
scanty ;  yet  one  may  be  written  ;  for  if  we  collect  only  Avell-marked  ex- 
amples of  the  disease,  their  histories  will  be  found  consistent  with  one 
another,  and  distinct  from  those  of  the  other  groups  of  cancers. 

Among  twenty  cases,  fifteen  occurred  in  men,  and  five  in  women:  a 
preponderance  on  the  male  side  approximating  that  observed  in  epithe- 
lial cancers,  and  (if  we  may  trust  to  a  result  from  so  few  cases)  con- 
trasting, in  a  striking  manner,  with  the  distribution  of  medullary  and 
scirrhous  cancers. 

Among  nineteen  of  these  patients,  five  were  between  10  and  20  years 
old ;  nine  between  20  and  30 ;  four  between  30  and  40 ;  one  between 
40  and  50  :  proportions  which  again  do  not  correspond  with  those  in 
any  other  form  of  cancer. 

Among  thirteen  of  the  patients,  five  distinctly  referred  to  injury  as 
the  origin  of  the  cancer,  and  two  to  previous  disease  in  the  part :  the 
others  assigned  no  cause. 

The  growth  of  osteoid  cancers  is  generally  rapid,  and  accompanied 
with  severe  pain  in  and  about  their  seat ;  their  multiplication  in  the 
lymphatics  and  in  distant  parts  takes  place  with  proportionate  rapidity ; 
and  intense  cachexia  occurs  early  in  their  course.  There  are  excep- 
tions to  these  things  ;  but  in  all  these  respects  the  majority  of  the  osteoid 
cancers  appear  as  malignant  as  the  medullary,  and  are  as  quickly  fatal. 

Among  fourteen  cases,  of  which  the  ends  are  recorded,  three  died  in 
consequence  of  amputations.  Of  the  other  eleven,  four  underwent  no 
operation,  and  all  died  in  or  within  six  months  from  the  first  notice  of 
the  disease.  Of  the  remaining  seven,  in  all  of  whom  the  disease  was 
once  or  more  removed,  and  in  all  of  whom  it  recurred  before  death, 
two  died  in  the  first  year  of  its  existence,  one  in  the  second,  one  in  the 
third ;  but  one  lived  for  seven  and  a  half  years,  another  for  twenty- 
four,  and  another  for  twenty-five  years. 

In  all  the  instances  of  speedy  death,  secondary  osteoid  cancers  ex- 
isted, and  the  result  was  probably  to  be  assigned  to  these  and;  to  the 
coincident  cancerous  cachexia ;  for  the  primary  growths  have  little 
tendency  to  ulcerate  or  protrude,  and  they  seem  to  contribute  directly 
to  death  by  their  pain  alone.  In  the  instances  of  life  extended  beyond 
twenty  years,  the  disease  appeared  to  recur  only  near  its  primary  seat. 

The  most  frequent  seats  of  the  secondary,  or  recurrent,  osteoid  can- 
cers are  the  lymphatic  glands,  in  the  line  from  the  primary  seat  to  the 
thoracic  duct,  the  lungs,  and  the  serous  membranes  :  but  it  is  not  limited 
to  these ;  it  may  be  found  even  in  the  bloodvessels,  as  in  a  case  which 


652  OSTEOID     CANCER. 

I  shall  relate,  and  has  been  traced  in  the  thoracic  duct.*  Its  condi- 
tion in  these  secondary  seats  need  not  be  described :  in  structure  it 
resembles  in  them  the  primary  disease,  with  only  such  diflFerences 
as  are  already  mentioned ;  in  plan  it  is  like  the  growths  or  infil- 
trations of  secondary  medullary  cancers  in  the  same  parts.  But  it 
is  to  be  observed  that,  sometimes,  the  secondary  cancer  is  medullary, 
without  osseous  matter.  I  have  mentioned  three  instances  of  this  (p. 
646),  and  Professor  Langenbeck  told  me  that  he  once  removed  an  upper 
jaw  with  a  bony  growth,  and  the  patient  died  soon  after  with  well-marked 
medullary  cancer  in  the  lungs.  The  reverse  may  occur :  for  the  same 
distinguished  surgeon  told  me  that  he  once  removed  a  humerus  with  a 
medullary  cancer,  and  the  patient  died  with  osseous  tumors  in  the  lungs.f 

The  ordinary  course  of  osteoid  cancers  may  be  known  by  the  fore- 
going account  of  them,  and  by  the  cases  recorded  by  Miiller  and  Mr. 
Stanley.!  But  deviations  from  this  course  are  sometimes  observed, 
which  it  may  be  well  to  illustrate  by  cases  that  displayed  the  disease 
in  an  unusually  acute,  and  an  equally  unusual  inactive,  form. 

A  girl,  15  years  old,  was  admitted  into  St.  Bartholomew's  Hospital, 
with  general  feebleness  and  pains  in  her  limbs,  which  had  existed  for 
two  or  three  weeks.  They  had  been  ascribed  to  delayed  menstruation, 
till  the  pain,  becoming  more  severe,  seemed  to  be  concentrated  about 
the  lower  part  of  the  back  and  the  left  hip.  A  hard  deep-seated  tu- 
mor was  now  felt,  connected  with  the  ala  of  the  left  ilium.  This  gra- 
dually increased,  with  constant  and  more  wearing  pain  ;  it  extended 
towards  the  pelvic  and  abdominal  cavities  ;  the  patient  became  rapidly 
weaker  and  thinner  ;  the  left  leg  swelled  ;  sloughing  ensued  over  the 
right  hip;  and  thus  she  died  cachectic  and  exhausted,  only  3|-  months 
from  her  first  notice  of  the  swelling. 

A  hard  lobulated  mass  was  found  completely  filling  the  cavity  of  the 
pelvis,  and  extending  across  the  lower  part  of  the  abdominal  cavity. 
It  was  firmly  connected  with  the  sacrum,  both  ischia,  and  the  left  ilium  ; 
it  held,  as  in  one  mass,  all  the  pelvic  organs ;  and  the  uterus  was  so  im- 
bedded in  it,  and  so  infiltrated  with  a  similar  material,  that  it  could 
scarcely  be  recognized. 

The  general  surface  of  this  growth  was  unequal  and  nodular.  It 
was  composed  of  a  pearly-white  and  exceedingly  hard  structure,  in 
which  points  of  yellow  bony  substance  were  imbedded,  and  which  had 
the  characters  of  osteoid  cancer  perfectly  marked.     The  ilium,  where 

*  Cheston,  in  Philos.  Trans.,  1780,  vol.  Ixx. 

J  A  case  is  reported  by  Mr.  Quain  in  Brit.  Assoc.  Med.  Jal.,  Oct.  26,  1855,  p.  70,  of 
osteoid  cancer,  in  which  there  were  secondary  formations  both  in  the  cavities  of  the  thorax 
and  abdomen.  The  microscopic  appearances  are  related  by  Drs.  Hillier  and  Jenner,  in 
Trans.  Path.  Soc,  vol.  vi,  p.  317. 

j  L.  c.  See  also  Gerlach's  two  cases  (1.  c),  and  that  by  Hunter,  in  the  Catalogue  of  the 
College  Museum,  vol.  ii,  p.  176. 


VILLOUS     CANCER.  653 

the  tumor  was  connected  with  it,  had  the  same  half  fibrous  and  half 
bony  structure  as  the  tumor  itself. 

The  common  iliac  veins,  their  main  divisions,  and  others  leading  into 
them,  passed  through  the  tumor,  and  were  all  distended  Avith  hard  sub- 
stance like  the  mass  around  them.  From  the  common  iliac  veins  a  con- 
tinuous growth  of  the  same  substance  extended  into  the  inferior  cava, 
which,  for  nearly  five  inches,  was  distended  and  completely  obstructed 
by  a  cylindriform  mass  of  similar  fibrous  and  osseous  substance,  IJ 
inches  in  diameter.  At  its  upper  part  this  mass  tapering  came  to  an 
end  near  the  liver. 

The  lower  lobe  of  the  right  lung  was  hollowed  out  into  a  large  sac, 
containing  greenish  pus  and  traversed  by  hard  coral-like  bands,  which 
proved  to  be  branches  of  the  pulmonary  artery  plugged  with  firm  white 
substance  intermingled  with  softer  cancerous  matter,  and  resembling 
the  great  mass  of  disease  in  the  pelvis.  The  rest  of  the  lung  was 
healthy,  with  the  exception  of  some  scattered  grayish  tubercles  ;  and 
so  ivas  the  left  lung,  except  in  that  there  were  a  few  small  abscesses 
near  its  surface,  with  hard,  bone-like  masses  in  their  centres,  like  those 
in  the  branches  of  the  right  pulmonary  artery.  The  skull,  brain,  peri- 
cardium, heart,  and  all  the  abdominal  organs,  were  healthy.* 

I  suppose  that  few  cases  of  osteoid  cancer  can  be  found  equal  with 
this  in  the  acuteness  of  their  progress.  The  opposite  extreme  is  illus- 
trated by  a  case  communicated  tome  by  Mr.  Thomas  Simpson,  and  ex- 
actly corresponding  with  one  of  which  the  specimens  are  in  the  Museum 
of  the  College. f  A  swelling  appeared  in  the  upper  arm  of  a  woman 
82  years  old.  After  ten  years'  growth,  Avhen  it  had  increased  to  seven 
pounds  weight,  it  was  removed  by  Mr.  Hewson.  It  had  the  characters 
of  osteoid  cancer.  The  patient  completely  recovered  from  the  opera- 
tion ;  but,  about  a  year  after  it,  a  new  tumor  appeared  about  the  hu- 
merus, and  at  the  end  of  four  years  had  acquired  a  huge  size,  and  a 
weight  of  15|^  pounds.  For  this,  which  proved  to  be  a  similar  osteoid 
growth,  the  arm  was  amputated  at  the  shoulder-joint.  She  recovered 
from  this  operation  also ;  but  the  disease  returned  in  the  scapula,  and, 
in  about  10  years  after  the  amputation,  and  24  years  from  the  begin- 
ning of  the  disease,  she  died. 

VILLOUS    CANCER. 

The  name  of  Villous  Cancer  (Zottenkrebs  of  Rokitansky)  has  been 
applied  to  growths  possessing  a  papillary  or  villous  form,  ^with  inter- 
spersed cancerous  elements,  which  occasionally  project  from  mucous  or 
other  surfaces.  But  it  is  probable  that  under  this  name  may  have  been 
included  growths  having  the  villous  character,  which  in  their  structure 

*  The  specimens  from  this  case  are  in  the  Museum  of  St.  Bartholomew's, 
f  No.  3244-5-5  a. 


654  '  VILLOUS    CANCER. 

were  altogether  innocent  and  analogous  to  the  common  warts  of  the 
skin  and  denser  mucous  membranes. 

The  bladder,  colon,  and  rectum  appear  to  be  sometimes  the  seats  of 
such  simple  growths,  and  cases  in  which,  with  the  existence  of  most 
decided  villous  structures,  the  negative  evidence  against  cancer  seems 
complete,  are  recorded  more  especially  by  Mr.  Sibley.*  Again,  it 
would  appear  that  the  dendritic  growths  of  a  medullary  cancer  may  not 
unfrequently  assume  a  villous  or  papillary  character,  so  that  the  cell 
elements  of  this  form  of  cancer  may  be  mingled  with  projecting  villi. f 
And,  perhaps  even  more  readily,  the  finely  warty  or  cauliflower-like 
cylindriform  epithelial  cancers  may  take  on  the  villous  foi-m.J;  But 
though  many  new  villous  growths  may  thus  be  excluded  from  the  group 
of  villous  cancers,  yet  there  would  still  appear  to  be  cases  to  which  the 
term  with  advantage  may  be  applied,  so  that  it  may  be  well  not  alto- 
gether to  discard  it.  For  these  cases,  then,  both  for  their  own  sake, 
and  for  the  illustrations  they  afford  of  a  remarkable  mode  of  growth, 
which  probably  prevails  throughout  a  wide  range  of  morbid  structure, 
a  separate  description  may  be  given. § 

As  I  have  had  no  opportunity  of  minutely  examining  a  good  recent 

*  Trans.  Path.  Soc,  vol.  vii,  pp.  214,  256.  Cases,  apparently  of  an  analogous  nature,  are 
related  by  Mr.  Shaw,  ib.,  vol.  v,  p.  200;  Mr.  H  Thompson,  vol.  viii,  p.  262;  Mr.  Bryant, 
vol.  xi,  p.  153;  and  by  Mr.  Quain. 

t  Dr.  Bristowe  (Trans.  Path.  Soc,  vol.  xi,  p.  94)  relates  a  case  of  cancer  of  the  stomach, 
in  which  cancerous  growths  were  mingled  with  villous  and  papillary  projections. 

1  In  St.  Bartholomew's  Museum  are  specimens  of  such  villous  cancers  in  the  gall-bladder 
(xix,  3)  and  on  the  peritoneum  (xvi,  60).  See  also  a  case  by  Mr.  H.  Gray  (Trans.  Path. 
Soc,  vol.  vi,  p.  183)  of  villous  and  epithelial  cancer  of  pharynx  and  ossophagus,  and  one  by 
Mr.  Sibley  (ib.,  vol.  viii,  p.  18)  of  villous  growth  on  the  dura  mater. 

I  A  very  well-marked  recent  specimen  of  villous  growth  from  the  free  surface  of  the 
mucous  membrane  of  the  bladder  has  been  lately  shown  to  the  editor  by  his  friend  Dr.  Jo- 
seph Bell.  Within  the  villi  of  which  this  growth  was  composed,  cell-forms,  undoubtedly 
cancerous,  were  infiltrated  in  large  numbers,  so  that  the  specimen  may  be  cited  as  an  illus- 
tration of  the  existence  of  a  form  of  cancer  to  which  the  term  villous  may  be  especially  ap- 
plied. Through  Dr.  Bell's  kindness  he  is  enabled  to  give  the  following  note  of  the  appear- 
ances :  "  About  l^ths  of  the  surface  of  the  mucous  coat  of  the  bladder  was  covered  with  a 
growth  which  seemed  to  consist  (when  viewed  by  the  naked  eye)  of  innumerable  slender 
filaments  matted  together  like  the  pile  of  a  very  loose  velvet.  It  was  pale  in  color,  but 
streaked  with  a  dusky  pink  and  yellow.  Examined  microscopically,  it  was  found  to  con- 
sist of  slender,  villous  processes  growing  directly  from  the  surface  of  the  mucous  membrane 
itself,  and  not  connected  to  it  by  any  constricted  pedicle.  These  villi  varied  considerably 
in  shape,  some  being  elongated,  others  again  more  stunted.  From  the  sides  of  some,  flask- 
shaped  processes  projected  at  intervals,  whilst  others  again  had  club-shaped  extremities. 
Some  were  apparently  filled  with  small,  transparent,  closely-packed  cells,  whilst  in  others, 
cells  possessing  the  same  characters  were  more  sparingly  distributed,  and  in  some  cases  the 
ceils  were  especially  arranged  around  the  wide  capillary  loop  situated  in  the  centre  of  the 
villus.  From  the  villi  the  cells  could  be  readily  traced  into  the  mucous  membrane  and  sub- 
mucous tissue,  which  v^^ere  closely  infiltrated  with  them.  In  many  of  the  villi,  but  espe- 
cially in  the  larger  ones,  fat  granules,  sometimes  collected  into  large  masses,  existed,  which 
gave  to  the  villi  a  yellow  color." 

The  case,  which  presented  several  features  of  interest,  will  shortly  be  published  in  full 
by  Dr.  Bell.  The  specimen  in  its  characters  very  closely  corresponded  with  the  description 
given  by  Rokitansky  of  the  "dendritic  vegetation"  quoted  in  the  text. 


VILLOUS     CANCER.  655 

specimen  of  villous  cancer,  I  will  therefore  describe  their  construction 
in  an  abstract  of  E-okitansky's  essay.* 

The  excrescence  consists,  in  its  stem,  of  a  fibroid  membranous  struc- 
ture, on  which  the  branches  and  villous  flocculi  are  borne,  as  larger  and 
smaller  pouch-like  and  flask-shaped  buddings,  or  sproutings  of  a  struc- 
tureless hollow  tissue. 

The  "dendritic  vegetation,"  of  which  these  sproutings  are  an  ex- 
ample, has  been  already  often  referred  to,  especially  in  the  account  of 
the  stroma  of  medullary  cancers  (p.  574),  which  stroma  is,  indeed,  only 
another  modification  of  the  same  plan  of  growth  as  the  villous  cancers 
exemplify  in  a  clearer  form.  Other  examples  are  in  the  endogenous 
growths  of  cysts ;  in  the  Lipoma  arborescens  of  Mliller,  i.  e.,  the  tufted 
and  villous  growths  on  synovial  membranes ;  and  in  the  intra  cystic 
growths  of  thyroid  and  other  gland-substance,  illustrated  in  Lecture 
XXIII.  ' 

The  "dendritic  vegetation"  appears  originally  as  a  hollow  club- 
shaped  or  flask-shaped  body,  consisting  of  a  hyaline  structureless 
membrane.  It  is  either  clear  and  transparent  or  opaque,  i.  e.,  filled 
with  granules,  nuclei,  and  nucleated  cells  (Fig.  9T,  p.  574) :  externally, 
it  is  either  bare  or  covered  with  epithelium.  The  vegetation  does  not 
usually  develop  itself  into  villous  growths  directly  on  the  mucous  or 
other  surface  on  which  it  rests,  but  on  the  bars  of  some  previously 
formed  meshed-work,  such  as  is  described  at  p.  574.  The  further  de- 
velopment of  the  vegetation  is  commonly  in  one  of  two  chief  plans. 
Either  the  membranous  flask  grows  uniformly  into  a  sac,  which  contains 
a  serous  fluid,  or  is  filled  with  a  delicately  fibrous  meshed-work ;  or  else 
it  grows  and  sprouts  in  various  degrees  and  methods.  Of  this  sprout- 
ing growth,  which  alone  is  illustrated  in  villous  cancers,  there  are  three 
types.  They  are  represented  in  the  adjoining  copy  of  Rokitansky's 
sketches. 

In  the  first  (Fig.  Ill,  a),  the  flask  grows  out  in  low,  nearly  hemi- 
spherical sprouts.  These  may  contain  serous  fluid,  as  in  the  cystic 
disease  of  the  choroid  plexuses  ;  or  they  may  be  filled  with  gland  struc- 
tures, as  in  the  thyroid  and  mammary  intracystic  growths  ;  or  they 
may  contain  and  be  covered  with  cancerous  structures,  as  in  the  in- 
stance of  the  small  excrescences  within  a  cyst  in  a  cancerous  kidney, 
from  which  Fig.  Ill,  A,  was  draAvn. 

In  the  second  type  (Fig.  Ill,  b)  the  flask  grows  lengthwise  into  a 
tube,  and  shoots  out  new  ones,  which  grow  to  secondary  tubes,  and 
again  shoot  out  others,  which  grow  to  tertiary  tubes,  and  so  on.  On 
these  outgrowths  abundant  broader  sprouts  and  buds  appear.  Thus  a 
multiformly  ramified  dendritic  structure  is  produced.  Its  sprouts  may 
be  filled  with  connective  tissue,  or  fat  (as  in  Lipoma  arborescens),  or 
with  cartilage  and  bone  (as  in  the  pendulous  growths  of  these  tissues 

*  Ueber  der  Zottenkrebs  in  the  Sitzungsberichte  der  Kais.  Akad,  April,  1852. 


656 


VILLOUS    CANCER. 


within  joints) ;  or  they  may  contain  and  be  covered  with  the  elements 
of  the  cancer,  as  in  the  villous  cancer  of  the  urinary  bladder,  of  which 
part  is  sketched  in  Fig.  Ill,  b.  . 

In   the   third  type,  illustrated  by  Figi  111,  C,  from  another  villous 

Fig.  111.* 


cancer  of  the  bladder,  the  flask  grows  with  considerable  dilatation  into 
a  stem,  which  gives  off  branches,  that  do  not  ramify  further,  but  break 
up  at  once  into  a  great  number  of  flask-shaped  sprouts. 

The  usual  arrangement  of  the  bloodvessels  of  the  dendritic  vegeta- 
tions is  that  (as  in  the  synovial  fringes  and  the  villi  of  the  chorion)  a 
vessel  runs  along  the  contour  of  the  vegetation,  forming  frequent 
loops,  and  supplying  to  the  stem,  as  well  as  to  each  of  the  sprouts  and 
branches,  an  ascending  and  a  descending  vessel.  There  are,  however, 
pouches  in  the  vegetation  in  which  only  a  single  vessel  exists,  and  ter- 
minates with  a  rounded  end.  The  vessels  are  generally  large  examples 
of  the  so-called  colossal  capillaries,  thin-walled,  with  longitudinal,  and 
sometimes  also  transverse,  oval  nuclei  in  pellucid  membrane. f 

In  structure,  the  vegetation  in  villous  cancers  is  often  hyaline ;  that 
is,  it  contains,  besides  a  clear  fluid,  no  tissue-elements  ;  but  it  often 
contains,  together  with  its  bloodvessels,  a  quantity  of  elementary  gra- 
nules, nuclei,  and  cells,  and,  especially  at  the  ends  of  its  sprouts,  struc- 
tureless, simple,  and  laminated  vesicles.  On  its  exterior,  the  elements 
of  a  medullary  or  melanotic  cancer  juice  adhere  to  it,  consisting  of  nu- 
cleated cells  of  various  shapes,  which  form  a  soft,  or  a  more  consistent, 
deposit,  and  are  often  present  in  such  quantity  that  they  make  up  the 
greater  part  of  the  morbid  mass,  into  which  then  the  vegetations  seem 
to  grow. 

In  other  cases,  a  fibrous  texture  develops  itself  in  the  interior  of  the 
vegetation,  and  with  it  cancerous  elements  form,  like  those  of  the  exo- 
genous formation  just  mentioned.  In  this  state  the  villous  cancer,  in 
consequence  of  the  accumulation  of  the  fibrous  and  cancerous  struc- 
tures, appears  asa  collectionof  excrescences,  which,  in  their  stems  as  well 

*  Fig.  111.  Methods  of  growth  of  the  "  dendritic  vegetation,"  from  Rokitansky.  Mag- 
nified 30  times  :  explained  in  the  text. 

t  Gerlach's  account  of  the  bloodvessels  nearly  corresponds  with  this  (Der  Zottenkrebs 
und  das  Osteoid,  Taf  i,  Fig.  3). 


VILLOUS     CANCER.  657 

as  in  their  branches  and  sprouts,  and  especially  towards  their  free  ends, 
are  swollen  thick  and  big.  They  are  here  filled  with  a  delicately  fibril- 
lated  meshed- work,  turgid  with  medullary  cancer  juice  ;  and,  as  their 
swollen  ends  are  often  mutually  compressed,  the  whole  appears  like 
foliage  growing  on  shorter  or  longer  stems. 

When  the  villous  cancer  is  cut  through  to  its  base,  one  finds  a  to- 
lerably abundant  porous  fibrous  texture,  which,  on  nearer  examination, 
presents  a  compressed  meshed-work  traversed  by  fissure-like  apertures. 
Its  bars  consist  of  a  hyaline  substance  beset  with  oblong  nuclei  and 
nucleus-fibres,  and  here  and  there  dividing  into  filaments  of  connective 
tissue.  The  tissue  (e.  g.  of  the  mucous  membrane)  around  the  base  of 
the  cancer  is  traversed  by  a  whitish,  fine-meshed  trellis-work,  the  bars 
of  which  consist  of  nucleated  cells,  and  often  develop  delicate  promi- 
nences and  vesicles,  the  beginnings  of  the  kind  of  vegetation  from  which 
the  cancer  sprang. 

The  fissured  and  perforated  meshwork  in  the  interior  of  the  base  of 
the  villous  cancer  corresponds  with  the  stroma  of  ordinary  medullary 
cancers  (p.  574).  Both  are  constructed  on  the  plan  of  the  dendritic 
vegetation.  In  the  construction  of  the  stroma,  the  sprouting  growths 
become  a  meshed-work  by  partial  absorption  :  in  the  villi  of  the  villous 
cancer  they  lengthen  into  branching  tubes.  And  these  tubes  have,  on 
the  one  hand,  the  import  of  a  stroma,  in  that  the  cancerous  elementary 
structures  cover  them  and  fill  up  the  spaces  between  them,  as  they  do 
those  between  the  bars  of  the  more  ordinary  stroma.  But,  on  the 
other  hand,  the  tubes  have  a  nearer  and  distinctive  relation  to  the  can- 
cerous elements,  in  that  they  produce  those  elements  in  their  interior; 
so  that  there  is  an  endogenous  as  well  as  an  exogenous  production  of 
cancer-structures.  * 

In  all  the  instances  that  have  been  fully  examined,  these  structures 
have  been  like  those  of  medullary  or  melanotic  cancer.  But  I  believe 
Rokitansky  is  right  in  the  anticipation  that  certain  epithelial  cancers 
will  be  found  to  grow  on  the  same  plan  as  the  villous.  I  have  referred 
(p.  601)  to  instances  of  warty  epithelial  cancers  growing  where  they 
could  not  have  had  origin  in  natural  papillae :  Virchow  also  describes 
arborescent  epithelial  cancers  growing  in  cavities  where  no  papillse 
could  well  be  ;  and  I  have  seen  the  same  in  cysts  within  what  I  believe 
to  be  an  epithelial  cancer  of  the  clitoris. f  The  shapes  of  the  most  ex- 
uberant epithelial  cancers  so  imitate  those  of  the  villous  cancers  that 
it  seems  highly  probable  that  some  of  them  are  produced  by  the  den- 
dritic mode  of  growth  rather  than  by  the  enlargement  and  deformity 
of  papillse.' 

The  correspondence  of  the  stromal  structures,  and  the  exact  similarity 

*  A  description,  with  illustrative  drawings,  of  a  case  of  villous  cancer  of  the  uterus,  is 
given  by  Forster  in  his  Atlas,  pi.  24. 

f  Museum  of  St.  Bartholomew's,  xxxii,  39. 


658  COLLOID    CANCER. 

of  the  cancer-elements,  found  in  the  medullary  and  melanoid  cancers 
on  the  one  hand,  and  in  the  villous  cancers  on  the  other,  are  enough 
to  "warrant  us  in  regarding  these  as  varieties  of  the  more  general  form. 
This  view  is  confirmed  by  numerous  cases  in  which  the  central  and 
basal  parts  of  the  growth  are  like  common  medullary  cancer,  its  sur- 
face being  villous  ;  and  by  some  in  which  villous  cancers  appear  as  se- 
condary growths  with  primary  medullary  cancers  of  the  more  common 
kind  :  thus,  e.  g.,  the  former  occur  on  the  peritoneum,  with  the  latter 
in  the  ovaries.  It  may  be  anticipated  that  the  histories  of  the  villous 
cancers  will  equally  coincide  with  those  of  the  medullary  and  melano- 
tic ;  but,  as  yet,  the  cases  recorded  are  too  few  for  the  deduction  of 
any  general  rules. 

COLLOID    CANCER. 

Many  names  have  been  given  to  this  form  of  cancer, — Colloid,  Alveo- 
lar, Gelatiniform,  Cystic,  and  Grum-Cancer.  I  have  adopted  the  first, 
because  it  seems  to  be  now  most  frequently  used,  and  expresses  very 
well  the  most  obvious  peculiarity  of  the  diseased  structure,  the  greater 
part  of  which  is,  usually,  a  clear  flickering  or  viscid  substance,  like 
soft  gelatine. 

The  most  frequent  primary  seats  of  colloid  cancer  are  the  stomach, 
the  intestinal  canal,  uterus,  mammary  gland,  and  peritoneum  :  as  a 
secondary  disease,  it  affects  most  frequently  the  lymphatic  glands  and 
lungs,  and  may  occur  in  many  other  parts. 

To  the  naked  eye,  a  colloid  cancer  presents  two  chief  constituents  : 
an  opaque-white,  tough,  fibrous-looking  tissue,  which  intersects,  parti- 
tions, and  incloses  its  mass  ;  and  a  clear  soft  or  nearly  liquid  material, 
the  proper  "  colloid"  substance.  According  to  the  proportions  in  which 
these  are  combined,  the  general  aspect  of  the  disease  varies.  When 
the  fibrous  texture  is  predominant  (as  I  have  twice  seen  it  in  the  cen- 
tral parts  of  colloid  cancers  of  the  breast)  it  forms  a  vei'y  tough,  white, 
fascia-like  mass,  in  which  are  small  separate  cysts  or  cavities  filled 
with  the  colloid  substance.  In  the  opposite  extreme,  large  masses  of 
the  colloid  substance  appear  only  intersected  by  fibrous  white  cords  or 
thin  membranes,  arranged  as  in  areolar  tissue,  or  in  a  wide-meshed 
netAvork.  These  extremes  often  exist  in  difi"erent  parts  of  the  same 
mass,  and  with  them  are  various  intermediate  forms,  in  which,  probably, 
the  essential  characters  of  the  disease  may  be  best  learned.  In  these, 
the  cancerous  substance  appears  constructed  of  small  thin-walled  cysts, 
cells,  or  alveoli,  arranged  without  apparent  order,  and  filled  with  the 
transparent  colloid  substance.  The  cysts  or  alveoli  are,  typically,  of 
round  or  oval  form,  but  are  changed  from  this,  as  if  by  mutual  pres- 
sure ;  some  may  appear  closed,  but  the  great  majority  communicate 
with  those  around  them,  through  apertures  like  imperfections  in  their 
walls.     They  vary  from  an  inch  in  diameter  to  a  size  as  small  as  the 


MICROSCOPIC  STRUCTURE.  659 

naked  eye  can  discern.  The  largest  cysts,  and  the  least  abundant 
fibrous  tissue,  are  usually  at  or  near  the  surface  of  the  mass  ;  and  in 
these  large  cysts,  when  the  colloid  substance  is  emptied  from  them,  we 
can  generally  see  intersecting  bands,  or  incomplete  partitions,  as  if 
they  were  formed  by  the  fusion  of  many  cysts  of  smaller  size.  The 
walls  of  the  cysts  appear  formed  of  delicate  white  fibrous  tissue,  but 
cannot  be  separated  from  the  surrounding  substance,  and  are  continu- 
ous with  the  coarser  bands  or  layers  of  fibrous  tissue  by  which  the  can- 
cerous mass  is  intersected. 

The  colloid  matter  is,  in  different  parts  or  in  different  instances, 
various  in  consistence ;  resembling  a  thin  mucilage,  starch-paste,  the 
vitreous  humor,  size-gelatine,  or  a  tenacious  mucus.  In  its  most  nor- 
mal state,  it  is  glistening,  translucent,  and  pale  yellowish  ;  but  it  may 
be  colorless,  or  may  have  a  light  green,  gray,  pink,  or  sanguineous 
tint ;  and  may  become  opaque,  whitish,  or  buif-colored,  by  (appa- 
rently) a  fatty  or  calcareous  degeneration  ;  or,  in  the  extreme  of  this 
degeneration,  may  look  like  tuberculous  matter.  In  water,  or  in  spirit, 
it  oozes  from  the  alveoli,  and  floats  in  light  cloudy  flocculi ;  and  when 
the  surface  of  the  cancer  is  exposed  by  ulceration  or  by  rupture,  it  is 
discharged  from  the  opened  alveoli  and  lies  on  them  like  a  layer  of 
mucus. 

The  colloid  cancers  have  usually,  in  the  first  instance,  the  shape  of 
the  part  that  they  affect ;  for  they  are  always,  I  believe,  infiltrations 
of  the  affected  part,  whose  tissues  are  gradually  removed  and  super- 
seded by  their  growth.  But  the  growth  of  the  colloid  cancer  enlarges 
and  surpasses  the  part  in  which  it  is  seated,  and  produces,  in  such  an 
organ  as  the  breast  or  the  lymphatic  glands,  a  considerable  rounded 
and  tuberous  firm  swelling,  or,  in  such  a  one  as  the  stomach  or  the 
peritoneum,  a  flattened  expanded  mass,  with  more  or  less  of  nodular  or 
tuberous  projection. 

The  extent  of  growth  is  sometimes  enormous,  especially  in  the  peri- 
toneum, in  which,  as  in  a  case  related  by  Dr.  Ballard,*  the  greater 
part  of  the  parietal  and  much  of  the  visceral  portion  may  be  infiltrated 
with  the  morbid  structure,  either  in  a  nearly  uniform  layer,  or  in  nodu- 
lated swellings  formed  of  groups  of  cysts,  and  sometimes  projecting  far 
into  the  peritoneal  cavity.  The  cavity  itself  may,  in  these  cases,  con- 
tain free  colloid  matter,  discharged,  I  suppose,  from  the  open  superficial 
alveoli,  and  the  abdominal  walls  may  be  thus  distended  with  a  fluctua- 
ting vibrating  swelling  like  that  of  ascites,  f 

It  is  not  unfrequent  to  find  one  or  more  large  and  thick-walled  cysts 

*  Med.-Chir.  Trans.,  xxxi,  119. 

f  In  Dr.  Ballard's  case,  six  quarts  of  free  colloid  matter  were  removed  from  the  peritoneal 
cavity  after  death.  I  remember  an  exactly  similar  case  in  which,  I  think,  the  quantity  re- 
moved must  have  -been  greater,  and  in  vi'hich  it  certainly  appeared  to  be  derived  from  the 
dehiscence  and  constant  discharge  of  the  alveoli.  In  the  Museum  of  the  College,  No.  294, 
is  a  mass  of  peritoneal  colloid  cancer,  from  eight  to  ten  inches  in  its  diameters,  which  was 
removed  from  the  lower  surface  of  a  liver. 


660 


COLLOID     CANCER. 


near  or  attached  to  masses  of  colloid  cancer,  and  imitating  tlie  charac- 
ters of  such  proliferous  multilocular  cysts  as  are  found  in  the  ovaries. 
They  are  usually  filled  with  colloid  matter,  and  their  likeness  to  the 
ovarian  cysts  may  confirm  the  belief  that  many  of  the  latter  are  really 
colloid  cancers  of  the  ovaries. 

Moreover,  colloid  cancer  is  sometimes  found  mingled  in  the  same 
mass  with  medullary  cancer.  This  is,  indeed,  frequent  in  the  digestive 
canal.  Villous  and  melanotic  cancers  have  been  similarly  combined 
with  it  ;  and,  more  frequently,  in  difi'erent  parts  of  the  same  person, 
the  medullary  and  the  colloid  are  found  in  distinct  masses. 

Microscopic  examination  of  fragments  of  colloid  cancer  brings  into 
view  an  arrangement  of  delicately  fibrous  and  lamellar  structures — 
the  stroma— -imitating,  in  miniature,  the  larger  appearances  visible  to 

the  naked  eye.     Fine  tough  fibres, 
^'       '  or  fibred  membranes,  are  arranged 

in  curved  bundles  and  lamellae, 
which,  by  their  divergences  and 
interlacements,  encircle  or  inclose 
oval  or  spherical  spaces,  contain- 
ing the  colloid  substance. f  The 
inclosed  spaces  are  seldom  com- 
plete cavities ;  they  communicate 
freely  with  one  another  ;  and  both 
in  their  plan,  and  in  the  general 
aspect  of  the  tissue,  remind  one, 
as  Lebert  says,  of  the  structure  of 
a  lung,  with  its  communicating 
air-cells.  The  fibres  are  very  fine,  but  appear  stiff  and  tough,  not  un- 
dulating nor  easily  parting  ;  they  are  but  little  and  slowly  changed  by 
acetic  acid.  Elongated  nuclei  are  often  seated  on  these  fibres,  and 
sometimes,  Lebert  says,  elastic  fibres  are  mingled  with  them.  The  col- 
loid substance  fills  all  their  interspaces, — not  merely  the  cavities  which 
they  circumscribe,  but,  as  it  were,  mere  crevices  between  the  fibres, 
and  spaces  in  the  walls  of  the  larger  cavities. 

The  colloid  substance  generally  appears,  however  magnified,  clear 
and  structureless  ;  it  might  be  invisible  but  for  the  seeming  filamentous 
texture  produced,  as  it  often  is,  in  spread-out  masses,  by  its  folds  and 
creasings.  Sometimes  the  colloid  material  is  sprinkled  with  minute 
dots,  like  oily  or  fatty  molecules, |  which  to  the  naked  eye  may  give 

*  Fisf.   112.     Fibrous  tissue  of  a  colloid  cancer  of  the  breast.     Magnified  70  times. 

t  Mr.  Sibley,  in  a  paper  in  the  Trans.  Med.-Chir.  Soc,  vol.  xxxix,  p.  261,  states  that  the 
stroma  of  colloid  in  its  most  characteristic  form  assumes  the  shape  of  a  convoluted  membrane, 
which  in  places  is  so  thin  and  transparent,  that  its  presence  might  be  overlooked.  But  in 
other  places  well-defined  fibres  may  be  seen,  which  here  and  there  expand  so  as  to  be  con- 
tinuous with,  and  evidently  form  a  part  of,  the  membranous  stroma. 

X  But  the  observations  of  Dr.  Jenner  (Proc.  of  Pathol.  Soc,  1851-52,  p.  323)  make  it  pro- 
bable that  these  are  granules  of  phosphate  of  lime. 


MICROSCOPIC     STRUCTUEE. 


661 


it  a  peculiarly  milky  or  ochrey  aspect ;  and  sometimes  it  is  beset  with 
clusters  of  such  molecules,  resulting  apparently  from  the  degeneration 
of  imbedded  nuclei  or  imperfect  cells.  With  these,  also,  crystals  of 
the  triple  phosphate,  cholesterine,  and  some  peculiar  fatty  matter,* 
may  be  mingled. 

Lebertf  has  published  an  exact  analysis  of  this  colloid  matter  by 
Wurtz.  The.  main  results  are,  that  it  is  quite  unlike  any  variety  of 
gelatine,  being  insoluble  in  water,  and  containing  only  T  per  cent,  of 
nitrogen,  a  peculiarity  which  distinguishes  it  as  well  from  all  protein- 
compounds,  and  from  the  materials  of  which  (imperfectly  and  impurely 
as  they  have  been  examined),  the  essential  structures  of  other  cancers 
are  composed. 

Imbedded  in  the  colloid  substance,  but  in  very  uncertain  quantity, 
are  corpuscles  of  peculiar  form.  According  to  Lebert  (of  whose  de- 
scription and  sketches  I  again  gladly  avail  myself),  they  are  chiefly 
these  : 

(1)  Nucleated  cells  lie  free  in  the  colloid  substance,  or  inclosed  within 
large  brood-cells,  or  grouped  like  an  epithelium  on  the  boundaries  of 
the  alveoli  or  cysts.  These,  the  so-called  colloid  corpuscles,  are  small, 
granular,  moderately  transparent  cells,  of  irregular  shape,  from  soVoth 
to  3(5^5 Qth  of  an  inch  in  diameter,  with  small  nuclei  or  none.  These  are, 
probably,  cancer-cells  hindered  and  modified  in  their  development  by 
the  peculiar  circumstances  of  their  formation ;  for,  with  such  as  these, 
more  perfect  cancer-cells  are  sometimes  found. 

(2)  Large  compound  cells,  mother-cells  or  brood-cells,  which  in  typical 
specimens  (Fig.  113,  a)  are  from  ogoth  to  500th  of  an  inch  in  diameter, 

Fig.  11.34 


are  in  some  instances  very  numerous.  They  are  very  pale,  oval,  round, 
or  tubular,  and  lie  in  clusters:  some  of  them  display  a  lamellar  surface, 
indicated  by  concentric  boundary  lines  ;  and  they  inclose  one  large 
granular  nucleus,  or  several  of  smaller  size  imbedded  in  their  general 


*  Luschka,  in  Virchow's  Aichiv,  iv,  412. 
f  In  Virchow's  Archiv,  iv,  203. 

%  Fig.  113.     Structures  of  colloid  cancer  described  in  the  text.     From  Lebert  (Vircho\v"s 
Archiv,  B.  iv,  Taf.  v),  and  Rokitansky  (Ueber  die  Cyste,  Taf.  vi). 


662  COLLOID    CANCEE. 

granular  contents,  or,  together  with  such  nuclei,   complete  nucleated 
cells  like  cancer-cells. 

(3)  Large  laminated  spaces  (Fig.  113,  b)  are  also  found  of  nearly 
crystalline  clearness,  from  g'^th  to  y^o*^^  *^^  ^^  ^^^^  ^^  diameter.  These 
are  usually  oval  and  grouped,  so  as  to  form  a  soft  parenchyma.  Be- 
tween the  lamellae  of  their  walls  elongated  nuclei  are  scattered  ;  in  the 
interspaces  between  them  are  clusters  of  small  nucleated  cells  and  nu- 
clei ;  and  they  inclose  brood-cells  in  the  cavities  surrounded  by  their 
concentric  lamellae. 

Whether  we  consider  the  larger,  or  the  minuter,  characters  of  this 
colloid  cancer,  it  seems  difficult  to  believe  that  such  a  structure  can 
have  any  close  affinity  with  the  cancers  I  have  already  described  ;  they 
appear,  at  first  sight,  to  have  scarcely  anything  in  common.  Hence, 
some  have  denied  altogether  the  cancerous  nature  of  this  disease.* 
But  if  we  look,  not  to  its  structure  alone,  but  as  well  to  its  clinical  his- 
tory (so  far  as  it  is  illustrated  by  the  great  majority  of  the  recorded 
cases),  we  shall  find  in  it  all  the  distinctive  features  of  the  cancers. 
Thus  (1),  its  seats  of  election  are,  remarkably,  those  in  which  the  me- 
dullary cancers  are,  at  the  same  time  of  life,  most  apt  to  occur ;  (2) 
like  the  typical  cancers,  the  colloid  infiltrates,  and  at  length  supersedes 
and  replaces,  by  substitution,  the  natural  tissues  of  the  affected  part ; 
(3)  like  them,  also,  it  is  prone  to  extend  and  repeat  itself  in  lymphatic 
glands,  the  lungs,  and  other  parts  near  to  or  distant  from  its  primary 
seat;t  (4)  the  colloid  is  often  associated  with  other  forms  of  cancer  in 
the  same  mass,  or  in  different  tumors  in  the  same  person ;  (5)  it  appears 
as  apt  as  any  other  form  to  recur  after  removal ;  (6)  it  may  be  derived, 
hereditarily,  from  a  parent  having  scirrhous  cancer,  or  a  parent  with 
colloid  may  have  offspring  with  medullary  cancer. 

These  facts  seem  enough  to  prove  the  right  of  including  the  colloid 
with  the  generally  received  forms  of  cancer ;  certainly  they  are  enough, 
if  we  can  explain  the  peculiarities  of  the  colloid  cancer  as  the  result  of 
any  known  morbid  process  in  such  elemental  structures  as,  in  other 
conditions,  might  have  been  conformed  to  the  ordinary  types  of  cancer. 
And  such  an  explanation  is  not  impossible,  for,  as  Bokitansky  shows, 
the  colloid  cancer  has  a  near  parallel  in  many  cyst-formations  in  the 
normal  structures,  and  especially  in  those  forms  of  bronchocele  in  which 

*  Mr.  Sibley  especially,  from  an  examination  of  nine  cases,  which  have  fallen  under  his 
own  observalion,  has  concluded  that  colloid  is  a  disease  'perfectly  sui  generis,  and  is  neither 
of  a  cancerous  nature,  nor  frequently  associated  with  cancer. 

■f  Colloid  cancer  was  thus  multiplied  in  ten  out  of  eleven  cases  recorded  by  Lebert.  In 
a  case  by  Dr.  Warren  (Med.-Chir.  Trans.,  vol.  xxvii),  the  multiplication  was  to  an  amount 
scarcely  surpassed  by  any  medullary  cancers.  It  is  true  that  it  is  not  unfrequently  limited 
to  the  stomach,  or  rectum  and  the  adjacent  lymphatic  glands ;  but  this  is  equally  observable 
in  the  cases  of  villous  and  other  medullatry  cancers,  and  I  suspect  is  only  an  example  of  a 
general  rule,  that  cancers  (of  whatever  kind)  on  exposed  surfaces  are,  on  the  whole,  more 
apt  to  remain  single  than  those  growing  in  other  parts. 


RELATIONS    TO     OTHER    CANCERS.  663 

abundant  cysts,  full  of  viscid  fluid,  are  formed  in  the  growing  thyroid 
gland.  It  seems,  therefore,  a  reasonable  hypothesis  that  the  peculiari- 
ties of  the  colloid  or  alveolar  cancer  are  to  be  ascribed  to  cystic  disease 
occurring  in  elemental  cancer-structures.  Such  a  cystic  disease  may 
ensue  in  a  medullary  or  other  cancer  already  formed ;  but  in  the  well- 
marked  and  uniformly  constructed  colloid  cancer,  it  is  probable  that 
the  deviation  to  the  cystic  form  ensues  in  the  very  earliest  period  of 
the  cancer-structures,  while  each  element  is  yet  in  the  nascent  or  rudi- 
mental  state. 

Such  may  be  the  explanation  of  the  structures  of  those  cancers  in 
which  the  formation  of  cysts  is  cai^ied  to  its  maximum ;  and  I  have 
reserved  for  this  place  an  account  of  the  various  combinations  of  cysts 
with  cancers  of  all  kinds, — combinations  giving  rise  to  many  singulari- 
ties of  appearance,  of  which  I  omitted  the  description  in  earlier  Lec- 
tures, that  I  might  once  for  all  endeavor  to  explain  them. 

And  first,  we  may  divide  these  cases  into  those  in  which  the  cysts  are 
formed  independently  of  the  cancer-structures,  and  those  in  which  they 
are,  or  appear  to  be,  derived  from  them. 

In  the  first  class  we  may  enumerate  many  cases  in  which  cysts  and 
cancers  are  in  only  accidental  proximity.  For  example,  a  scirrhous 
cancer  may  occupy  part  of  a  mammary  gland,  in  the  rest  of  which  are 
many  cysts  that  are  in  no  sense  cancerous,  or  of  which  the  chief  lacti- 
ferous tubes  are  dilated  into  pouches  or  cysts  (see  page  520).  And 
such  a  cancer,  in  its  progress,  may  inclose  these  cysts,  and  they  may, 
I  believe,  remain  for  a  time  imbedded  in  it.  In  like  manner,  the  ovary, 
or  any  other  organ,  being  already  the  seat  of  common  cysts,  may  be- 
come the  seat  of  cancer ;  and  the  two  morbid  structures  may  become 
connected  though  not  related. 

In  this  class,  also,  may  be  reckoned  the  cases  in  which  cancers  grow 
from  the  walls  of  common  cysts  ;  i.  e.,  of  cysts  which  did  not  originate 
in  cancer-structures.  Thus  medullary  cancers  may  grow,  especially  in 
the  villous  form,  from  the  walls  of  ovarian  cysts,  which  have  themselves 
no  cancerous  appearance.* 

There  may  be  other  methods  in  which,  as  by  a  sort  of  accident,  cysts 
and  cancers  may  thus  become  connected  ;  but  these  are  the  chief  exam- 
ples. In  the  second  class,  including  those  in  which  the  cysts  appear  to 
be  derived  from  cancer-structures,  we  find  numerous  varieties,  which 
may  be  studied  as  a  series  parallel  with  those  of  the  simple  and  the 
proliferous  cyst-formations  in  the  natural  structures,  or  in  innocent 
tumors.     (Compare  Lectures  XXII  and  XXIII,  and  p.  388.) 

(a)  Cysts  filled  with  fluid,  like  serum  variously  tinted,  and  in  their 
general  aspect  resembling  the  common  serous  cysts  (p.  359),  are  often 
connected  with  cancers,  especially  with  those  of  the  medullary  form 
that  grow  quickly  or  to  a  great  size.     There  may  be  one  or  many  of 

*  Museum  of  St.  Bartholomew's,  xxxi.  20. 


664  COLLOID    CANCER. 

such  cysts,  lying  at  the  surface,  or  imbedded  in  the  substance,  of  the 
cancer.  Sometimes,  a  single  cyst  of  the  kind  enlarges  so  as  to  surpass 
the  bulk  of  the  cancer,  exceedingly  confusing  the  diagnosis.*  In  other 
cases  so  many  cysts  are  formed,  that  the  tumor  appears  almost  wholly 
composed  of  them,  the  cancerous  structure  only  filling  the  interstices 
between  their  close-packed  walls. f  Such  cases  might  justly  be  grouped 
as  a  "  cystic  variety"  of  medullary  cancer. 

(b)  Sanguineous  cysts  are  found,  as  often  as  the  serous,  in  connection 
with  the  medullary  and  other  cancers  ;  and  the  changes  which  the  blood 
undergoes  in  them  add  not  a  little  to  the  multiformity  of  appearances 
that  the  cancerous  masses  may  present. 

(c)  The  colloid  cysts  here  find  their  type  (p.  369) ;  not  only  as  con- 
structing the  peculiar  variety  of  cancer  just  described,  but  as  being 
mingled  with  ordinary  cancerous  growths  ;  for  it  is  common  to  find  with 
such  growths,  especially  in  the  abdomen  and  pelvis,  cysts  filled  with 
thickly-viscid  material,  like  mucus,  or  half-liquid  jelly,  in  all  the  varie- 
ties of  tint  that  we  see  in  the  cystic  disease  of  the  kidney  or  of  the 
thyroid  gland. 

(d)  While  thus  the  principal  varieties  of  simple  or  barren  cysts  are 
found  in  cancerous  growths,  as  in  the  original  tissues,  or  in  simple 
tumors,  so  may  we  also  trace  in  them  the  production  of  proliferous 
cysts  ;  i.  e.  of  cysts  from  whose  inner  surfaces  cancerous  growths  arise, 
corresponding  with  the  glandular  growths  that  may  fill  the  cysts  in  the 
mammary  or  thyroid  gland  (p.  379).  I  have  already  often  referred  to 
this  (pp.  389,  563,  &c.) ;  and  now,  need  only  add  that  such  endogenous 
growths  are  often  to  be  found  in  the  alveoli  of  the  colloid  cancer.  Clus- 
ters of  clavate,  or  flask-shaped  villous  processes,  like  those  formed  in 
the  early  stages  of  the  dendritic  vegetation  of  villous  cancer  (p.  655), 
spring  from  the  wall  of  the  alveolus.  With  laminated  walls,  and  can- 
cer-structures, or  new  cysts  in  their  cavities,  such  villous  growths 
crowded  together  probably  constitute  the  structures  which  I  have  de- 
scribed after  Lebert  (p.  661,  Fig.  113,  c).|  To  less  perfect  endogenous 
growth  we  must,  I  suppose,  ascribe  the  cancer-structures  which  are 
found  disorderly  mingled  with  the  colloid  contents  of  the  alveoli. 

Thus  is  the  general  anatomy  of  the  autogenous  cysts,  Avhich  I  de- 
scribed in  Lectures  XXII  and  XXIII,  paralleled  in  the  cysts  con- 
nected with  cancers.  It  may  sufiice  to  add  that  Rokitansky  has  traced 
a  similar  correspondence  in  their  origin  and  modes  of  development. 
The  account  of  the  formation  of  cysts  (p.  355,  e.  s.)  might  therefore  be 
again  read  here ;  with  the  understanding  that  the  nucleus,  or  smaller 
corpuscle,  by  whose  enormous  growth  a  cyst  is  formed,  is  here  a  cancer- 
ous element,  while,  in  the  cases  there  cited,  it  was   supposed  to  be  an 

*  Bruch  (Die  Diagnose  dev  Bosartigen  Geschwiilste,  p.  1):  Mns.  Coll.  Surg.,  281. 
f  Mus.  Coll.  Surg,,  277,  279,  2S0,  &c. ;  Mns.  St.  Bartholomew's,  xxxv,  14,  and  others. 
J  Compare  Lebert's  figures  with  those  of  Rokitansky  (Ueber  die  Cyste,  pi.  iv,  fig.  16). 


FIBROUS     CANCER.  665 

element  of  some  natural  tissue.  A  part  of  the  process  is,  moreover, 
already  exemplified  in  the  instance  of  epithelial  cancers  (p.  613,  Figs. 
104-5);  but  in  these,  the  cjsts,  produced  in  the  shape  of  laminated 
capsules,  are  very  rarely  barren,  or  filled  with  colloid  substance. 

Respecting  the  history  of  colloid  cancer,  the  number  of  well-recorded 
cases,  especially  of  those  in  which  external  parts  were  its  primary  seat, 
is  too  small  to  authorize  many  general  statements. 

Lebert  has  shown,  by  his  collection  of  cases,  that  it  generally  cor- 
responds Vy'ith  the  history  of  scirrhous  and  medullary  cancers  ;  that  the 
cases  are  about  equal  in  the  two  sexes ;  that  the  greatest  absolute  fre- 
quency is  at  the  middle  period  of  life;  that  the  disease  is  very  rare  in 
childhood;*  that  it  is  probably  of  somewhat  slower  average  progress  than 
the  medullary  cancers ;  that  it  more  slowly  affects  the  lymphatics  and 
the  organs  distant  from  its  primary  seat ;  that,  in  general,  its  symptoms 
in  each  part  correspond  with  those  of  other  cancers  affecting  the  same 
part :  and  this  summary,  I  believe,  includes  all  that  can  be  prudently 
said  upon  the  matter. 

FIBROUS    CANCER. 

Among  the  Cancers  it  may,  perhaps,  be  as  well  to  arrange  those 
tumors  which,  in  the  former  edition,  I  classed  by  the  name  of  Malig- 
nant Fibrous  Tumors,  with  the  Fibrous  Tumors.  For  although  in  their 
structure  they  do  not  contain  those  cell-forms  which  we  are  in  the  habit 
of  regarding  as  especially  cancerous  or  malignant,  yet  in  their  tendency 
to  recur,  and  to  produce  secondary  formations  of  a  similar  structure  in 
internal  organs,  and  in  the  influence  which  they  evidently  exercise  in 
shortening  the  lives  of  those  in  whom  they  occur,  they  present  so  many 
malignant  features,  that  they  seem  to  fall  more  naturally  into  this 
rather  than  the  innocent  class  of  tumors.  For  although  in  the  very 
large  majority  of  cases  the  structures  of  cancers  are  unlike  those  of  the 
normal  textures  of  the  body,  yet  there  are  instances  in  which  tumors, 
eminently  cancerous  or  malignant  in  history  and  habits,  approach  or 
even  attain  to,  close  similarity  to  the  natural  tissues.  And  here  I  might 
repeat  what  has  already  been  stated  in  the  lecture  on  recurrent  tumors, 
that  in  studying  the  histories  of  tumors  it  is  not  sufficient  to  content 
one's  self  with  a  mere  determination  of  their  structure.  The  "  life"  of 
tumors  is,  in  some  respects,  at  least  for  the  present,  a  better  basis  for 
classification  even  than  their  structure. 

One  of  the  best  marked  cases  in  which  a  tumor,  presenting  the  usual 
characters  of  a  fibrous  tumor,  not  only  recurred  after  removal,  but  even 
formed  secondary  tumors  of  a  like  nature  in  internal  organs,  occurred 

*  He  adduces  two  cases  of  children,  in  which  one  was  2,  the  other  J  J  years  old.  Mr. 
Edward  Bickersteth  has  observed  two  cases  of  colloid  cancer  of  the  kidney  in  children,  one 
of  whom  was  3^,  the  other  11,  years  old. 

43 


QQQ  FIBROUS    CANCER. 

in  a  poor  widow  who  was  under  my  care  several  years  ago.  She  was 
47  years  old,  and  had  been  crippled  with  acute  rheumatism  for  ten 
years  before  she  found  a  small  movable  tumor  in  her  right  breast. 
This  had  increased  slowly  till  seven  weeks  before  I  saw  her,  when,  hav- 
ing been  struck,  it  began  to  grow  very  rapidly,  and  became  the  seat 
and  centre  of  severe  pain.  It  increased  to  between  two  and  three  inches 
in  diameter,  was  nearly  spherical,  very  firm,  tense,  and  painful, — even 
extremely  painful.  I  supposed  it  to  be  a  large  hard  cancer,  and  re- 
moved the  whole  breast.  I  found  the  tumor  completely  separable  from 
the  mammary  gland,  which  was  pushed  aside  by  it,  but  was  healthy : 
the  cut  surface  could  not,  I  think,  have  been  distinguished  from  that 
of  an  ordinary  fibrous  tumor  of  the  uterus,  with  undulated  white  bands, 
excepting  that  part  of  it  had  a  suffused  purplish  tinge.*  The  whole 
substance  of  the  tumor  had  the  same  characters ;  and  in  microscopic 
examination,  often  and  lately  repeated,  I  could  find  nothing  but  tough, 
compact,  well-formed  fibrous  tissue,  with  imbedded  elongated  nuclei. 
On  boiling,  gelatine  was  freely. yielded.  In  short,  I  believe  it  would 
be  impossible  to  distinguish,  by  any  means  but  the  history,  this  tumor 
from  a  common  unmixed  fibrous  tumor  of  the  jaw  or  subcutaneous 
tissue.  . 

Three  months  after  the  operation  a  tumor  appeared  under  the  scar. 
It  grew  very  quickly,  and  felt  just  like  the  former  tumor.  After  two 
months  the  thin  scar  began  to  ulcerate,  and  the  integuments  around 
sloughed  ;  and  shortly  the  whole  of  this  tumor  was  separated  by  slough- 
ing, and  was  removed  entire.  This  also  had,  and,  in  the  Museum  of 
St.  Bartholomew's,  still  retains  every  character  of  the  common  fibrous 
tumor. 

After  the  separation  of  this  second  tumor,  a  huge  cavity  remained, 
with  sloughing  walls ;  then,  as  the  sloughs  cleared  away,  hard  knots, 
like  those  of  a  cancerous  ulcer,  grew  up  from  the  walls,  and  the  disease 
assumed  all  the  characters  of  a  vast  and  deep  hard  cancerous  sore.  In 
two  months  she  died.  I  found  the  ulcer  nearly  a  foot  in  diameter  :  its 
walls  were  formed  of  a  thick  nodulated  layer  of  hard,  whitish,  vascular 
substance,  like  the  firmest  kinds  of  medullary  cancer.  Both  lungs  con- 
tained between  twenty  and  thirty  small  masses  of  similar  substance 
imbedded  or  infiltrated  in  their  tissue  ;t  and  this  substance  I  have  re- 
cently again  examined,  and  found  to  be  a  complete  fibrous  tissue,  like 
that  of  the  first  tumor  removed.     I  found  no  similar  disease  elsewhere. 

All  the  characteristic  features  of  malignant  disease  were  thus  super- 
added to  the  growth  of  a  tumor  which  appeared  to  be,  in  every  structural 
character,  identical  with  the  common  innocent  fibrous  tumor.  Nearly 
the  same  events  were  observed  in  the  following  case :  In  1835,  a  man 

*  One  section  of  it  is  in  the  Museum  of  St.  Bartholomew's,  Ser.  xxxiv,  No.  24 ;  another  in 
the  College  Museum,  No.  223. 

f  Mus.  St.  Bartholomew's,  Ser.  xiv,  No.  43 ;  Mus.  Coll.  Surg.,  224. 


MALIGNANT    TUMORS. 


667 


114.* 


was  in  St.  Bartholomew's  Hospital,  under  the  care  of  Mr.  Earle,  with 
a  large  spheroidal  tumor,  lying  by  the  base  of  his  scapula,  and  extend- 
ing beneath  it.  It  was  removed ;  and  I  remember  that  it  was  easily 
enucleated  from  the  adjacent  parts,  and  was  called  "  albuminous  sar- 
coma;" but  it  was  not  preserved.  About  a  year  afterwards  the  man 
returned  with  a  yet  larger  tumor  in  the  same  situation.  Mr.  Skey  re- 
moved this,  together  with  a  large  portion  of  the  scapula,  to  both  surfaces 
of  which  it  was  closely  united.  The  wound  was  scarcely  healed,  when 
another  tumor  appeared,  and  increased  rapidly.  With  this  the  patient 
died,  and  growths  of  similar  substance,  white,  very 
firm,  and  nodulated,  were  found  beneath  that  part  of 
the  pleura  which  corresponded  with  the  growth  on  the 
exterior  of  the  chest.  I  state  these  particulars  from 
memory ;  but  I  have  found,  from  repeated  recent  ex- 
aminations, that  the  tumor  removed  by  Mr.  Skey  is  of 
fibrous  texture,  resembling  the  common  fibrous  tumors 
both  in  general  and  in  microscojjic  characters,  and, 
like  them,  yielding  gelatine  when  boiled,  f  It  is  lobed, 
with  partitions  of  connective  tissue,  and  its  several 
lobes  are  intersected  with  obscure  opaque-white  fibres  : 
it  is  tough,  compact,  and  heavy,  and  tears  with  an 
obscure  fibrous  grain.  It  is  easily  dissected  for  the 
microscope,  tearing  into  fasciculi,  and  appears  com- 
posed wholly  of  closely-placed  and  nearly  parallel  un- 
dulating filaments.  A  few  shrivelled  nuclei  appear 
among  the  fibres,  but  no  cells  are  distinguishable. 
Its  structure  is  represented  in  Fig.  114. 

To  these  cases  I  may  add,  though  it  be  an  imper- 
fect one,  that  of  a  woman  from  Avhose  back  Mr.  Law- 
rence removed  a  large  well-marked  fibrous  tumor, 
which  had  grown  nine  months  after  one  of  the  same  appearance  had 
been  removed  from  the  same  part.|  Before  removal,  this  was  judged 
by  all  who  saw  it  to  be  malignant ;  but  it  presented  a  genuine  fibrous 
structure,  and  could  not,  I  think,  be  distinguished  from  an  ordinary 
fibrous  tumor. 

Such  are  the  cases  which  make  me  believe  that  tumors  occur,  resem- 
bling in  all  respects  of  structure  and  chemical  composition  the  fibrous 
tumors  of  the  uterus  (excepting  their  muscular  fibres),  or  of  the  bones 


*  Fig.  114.  Tissue  of  a  malignant  fibrous  tumor  of  ihe  scapula  :  described  above.  Mag- 
nified about  400  times. 

t  It  is  in  the  Museum  of  St.  Bartholomew's,  Series  xxxv,  No.  51.  A  similar  case  by  JNIr. 
J.  Z.  Lawrence,  Diagnosis  of  Surgical  Cancer,  p.  73.  This  case  is  also  described  by  Mr. 
Sibley,  along  with  several  others  (Path.  Trans.,  vol.  viii,  p.  340),  as  a  multiple  fibrous  tumor. 
He  fully  recognizes  the  relations,  both  as  regards  structure  and  progress,  to  the  tumors  de- 
scribed in  the  text,  but  he  pronounces  against  their  cancerous  nature,  and  thinks  that  they 
have  close  analogies  to  the  recurring  fibroid  tumors. 

J  Mus.  St.  Bartholomew's,  Ser.  xxxv,  52. 


668  GENERAL    PATHOLOGY    OF     CANCER. 

or  subcutaneous  tissue,  yet  differing  from  these  in  that  they  pursue  a 
course  like  that  of  cancers,  recurring  after  removal,  growing  at  the 
same  time  in  internal  organs,  tending  to  sloughing  or  ulceration,  and 
in  the  latter  process  involving  adjacent  structures.  I  have  related  only 
cases  in  which  the  fibrous  structure  was  proved  by  microscopic  exami- 
nation ;  but  I  have  little  doubt  that  others  might  be  added  from  cases 
of  tumors  of  the  jaws  and  other  bones,  which  have  been  believed,  from 
their  general  appearance,  to  be  fibrous,  yet  have  pursued  a  malignant 
course.  I  will  only  add  that  these  are  not  such  growths  as  those  which 
Miiller  and  others  have  named  Carcinoma  fibrosum  (described  p.  530),- 
and  of  which,  I  believe,  that  they  are  always  infiltrations  in  the  substance 
of  the  affected  organs,  and  they  generally  include  cancer-cells  with 
their  fibrous  tissue,  and  that  they  have  in  this  tissue  such  hardness, 
stiffness,  and  other  peculiarities  of  structure,  as  make  it  easily  distin- 
guishable from  the  normal  fibrous  tissue  and  its  imitation  in  the  fibrous 
tumors. 


LECTURE    XXXIV. 

GENEEAL  PATHOLOGY  OF  CANCER. 

PART   I. 
CONDITIONS    PRECEDING   THE    CANCEROUS    GROWTH. 

I  PROPOSE,  in  this  and  the  next  Lecture,  to  consider  the  general 
pathology  of  all  the  forms  of  cancer  which  have  now  been  particularly 
described  ;  to  gather  a  general  history  of  them  from  the  statements 
made  concerning  each  ;  and  to  trace  how  the  laws  observed  by  them 
correspond  with  the  more  comprehensive  laws  of  all  specific  diseases. 

I  have  stated  on  page  347  the  hypothesis  which  I  think  we  must 
hold  concerning  cancers  :  namely,  that  they  are  local  manifestations  of 
certain  specific  morbid  states  of  the  blood  ;  and  that  in  them  are  incor- 
porated peculiar  morbid  materials  which  accumulate  in  the  blood,  and 
which  their  growth  may  tend  to  increase. 

In  the  terms  which  are  more  usual  in  discussions  respecting  the  nature 
of  cancers,  I  would  say  that  a  cancer  is,  from  the  first,  both  a  constitu- 
tional and  a  specific  disease.  I  believe  it  to  be  constitutional,  in  the 
sense  of  having  its  origin  and  chief  support  in  the  blood,  by  which  the 
constitution  of  the  whole  body  is  maintained ;  and  I  believe  it  to  be 
specific,  1st,  in  the  sense  of  its  being  dependent  on  some  specific  ma- 
terial, which  is  different  from  all  the  natural  constituents  of  the  body, 
and  different  from  all  the  materials  formed  in  other  processes  of  disease ; 
and  2dly,  in  the  sense  of  its  presenting,  in  the  large  majority  of  cases, 


CONDITIONS     PKECEDING    CANCEROUS    GROWTHS.  669 

structures  which  are  specific  or  peculiar,  both  in  their  form  and  in  their 
mode  of  life. 

The  evidences  for  this  hypothesis  appear  in  the  conformity  of  cancer 
to  the  other  specific  diseases,  for  which  a  similar  hypothesis  is  nearly 
proved  (Lect.  XX),  and  in  the  fitness  of  the  terms  which  it  supplies  for 
the  general  pathology  of  cancer. 

I  will  speak  in  this  lecture  of  the  conditions  that  precede  the  forma- 
tion of  a  cancerous  growth,  and  in  the  next  of  the  growth  itself. 

The  general  history  of  cancers,  and  their  analogy  with  other  diseases 
that  are,  in  the  same  senses,  specific  and  constitutional,  imply  that, 
before  the  formation  of  a  cancerous  growth,  two  things  at  least  must 
coexist :  namely,  a  certain  morbid  material  in  the  blood,  and  some 
part  appropriate  to  be  the  seat  of  a  growth  incorporating  that  material, 
some  place  in  which  the  morbid  material  may  assume,  or  enter  into,  or- 
ganic structure. 

The  existence  of  the  morbid  material  in  the  blood,  whether  in  the 
rudimental  or  in  the  effective  state,  constitutes  the  general  predisposi- 
tion to  cancer  ;  it  is  that  which  is  by  some  called  the  predisposing 
cause  of  cancer.  The  morbid  material  is  the  essential  constituent  of 
the  "cancerous  diathesis  or  constitution  :"  and  when  its  existence  pro- 
duces some  manifest  impairment  of  the  general  health,  independently 
of  the  cancerous  growth,  it  makes  the  primary  cancerous  cachexia  (see 
p.  553). 

That  which  evidently  makes  some  part  of  the  body  appropriate  for 
the  growth  of  a  cancerous  tumor  is  a  so-called  exciting  cause  of  cancer  ; 
but  it  is  a  cause  of  cancer  only  in  so  far  as  it  fits  some  part  for  the  local 
manifestation  of  a  disease  which  already,  in  its  essential  material,  exists 
in  the  blood. 

It  seems  very  important  to  keep  constantly  in  view  that  these  two 
conditions  must  coincide  before  the  appearance  of  a  cancerous  growth ; 
important  not  only  to  recognize  their  existence,  but,  if  we  can,  to 
measure  the  several  degrees  in  which,  in  each  case,  they  are  present ; 
because,  upon  our  recognition  of  the  shares  in  which  they  respectively 
contribute  to  the  production  of  the  cancerous  tumor,  must  depend  the 
chief  principles  of  practice  in  relation  to  the  removal  of  such  tumors. 
The  larger  the  share  taken  by  the  constitutional  element  of  the  dis- 
ease,— that  is,  by  the  cancerous  condition  of  the  blood, — in  the  pro- 
duction of  a  cancerous  growth,  the  less  is  the  probability  of  advantage 
to  be  derived  from  the  removal  of  that  growth ;  while,  on  the  other 
hand,  the  more  largely  the  local  state  enters  into  the  conditions  upon 
which  the  cancerous  growth  is  founded,  the  more  benefit  may  we  antici- 
pate from  the  removal  of  the  cancer  and  of  the  locality  with  it. 

So,  too,  in  our  considerations  of  the  mere  pathology  of  cancerous 
diseases,  it  seems  essential  to  have  a  just  regard  of  both  these  previous 
conditions.  If  we  look  at  only  a  certain  class  of  cases,  we  may  easily 
find  enough  to  persuade  ourselves  that  cancers  are,  from  the  first,  and 


670  GENERAL  PATHOLOGY  OF  CANCER. 

throughout  their  course,  wholly  constitutional  diseases;  or,  if  we  look 
exclusively  at  another  class,  which  are  as  truly  cancerous  as  the  first 
(according  to  any  natural  definition  of  the  term),  we  may  find  equal 
evidence  for  believing  that  they  are,  at  least  in  the  first  instance,  en- 
tirely local  diseases,  and  that  the  constitutional  afiection  which  may 
attend  them  is  only  something  consequent  upon  their  growth. 

When,  for  example,  we  see  that  certain  organs  are  much  more  liable 
than  others  to  the  growth  of  cancer,  and  that,  in  those  organs,  the 
growth  sometimes  follows  the  infliction  of  a  local  injury  or  some  pre- 
vious disease  ;  and  much  more  when  we  see,  as  in  the  case  of  the  scro- 
tal epithelial  cancers,  that  the  repeated  application  of  a  stimulus  such 
as  soot,  to  a  part  of  the  body,  will  lead  to  the  formation  of  cancer  in 
even  a  large  number  of  persons,  we  might  assume  that  the  growth  has 
its  origin  wholly  in  the  local  state,  and  that  whatever  may  follow  of  dis- 
ease in  other  parts  is  only  the  consequence  of  the  growth.  On  the 
other  hand,  when  we  consider  the  numerous  analogies  between  cancers 
and  the  admitted  specific  blood-diseases  ;  when  we  see  the  rapidity  of 
outbreak  with  which  cancerous  disease  sometimes  manifests  itself  in 
multiple  growths,  apparently  irrespective  of  the  locality  in  which  they 
are  produced,  and  how  sometimes  a  distinct  affection  of  the  general 
health,  intense  and  destructive,  exists  even  while  the  cancerous  struc- 
ture is  yet  trivial  or  unobserved  ;  and  when  we  see  the  insufficiency  of 
all  local  causes  to  excite  the  growth  of  cancer  in  some  persons,  we  might 
suppose  that  the  cancerous  disease  is  one  wholly  constitutional,  wholly 
dependent  on  some  morbid  condition  of  the  blood,  and  that  the  forma- 
tion of  the  tumor  is  but  as  an  accident  of  the  disease,  and  is  independent 
of  the  state  of  the  part  in  which  it  occurs. 

It  is  in  correspondence  with  these  classes  of  cases,  too  partially  ex- 
amined, that  two  distinct  opinions  are  commonly  entertained  respecting 
the  nature  of  cancer :  some  holding  that  it  is  from  the  beginning,  and 
throughout,  a  constitutional  disease  ;  and  others,  that  it  is,  in  the  first 
instance,  if  not  through  its  whole  course,  a  local  one.  The  reconcilia- 
tion, not  only  of  the  two  conflicting  opinions,  but  of  the  seemingly  con- 
flicting facts  upon  which  they  chiefly  rest,  is  to  be  found  in  this, — that 
the  complete  manifestation  of  cancer — the  formation  of  a  cancerous 
growth — is  suspended  till  such  a  time  as  finds  both  the  constitutional 
and  the  local  conditions  coexistent, — till  the  blood  and  the  part  are  at 
once  appropriate. 

I  might  show  how  consistent  the  belief  of  the  necessity  of  this  coin- 
cidence is  with  Avhat  is  known  of  other  specific  diseases.  But  let  me 
illustrate  it  by  two  cases,  such  as  may  frequently  be  met  with.  Bruch* 
records  the  following :  A  woman  had  a  child  at  eighteen  years  of  age. 
The  child  died  when  it  was  a  month  old,  and  her  breasts  were  left  to 
the  disturbance  which  usually  ensues  in  prematurely  arrested  lactation. 

*  Die  Diagnose  der  bOsartigen  Geschwulste,  p.  94. 


GENERAL  PATHOLOGY  OP  CANCER.  671 

At  tlie  age  of  thirty-four  she  received  a  blow  on  the  right  breast.  This 
was  followed  by  no  manifest  change  of  structure,  but,  for  some  days, 
by  severe  pains,  and  then,  for  a  much  longer  time,  by  feelings  of  swell- 
ing and  tension  at  the  menstrual  periods.  At  thirty-nine  she  received 
another  blow  upon  the  same  breast,  which  was  followed  by  an  increase 
of  pain.  Soon  afterwards  she  was  exposed  to  cold,  and  then  there  en- 
sued erysipelatous  inflammation  of  the  breast,  followed  by  induration 
of  the  part  of  the  mammary  gland.  This,  however,  continued  without 
change  for  four  years  ;  but  then,  after  monorrhagia,  a  tumor  appeared 
in  the  breast.  When  this  was  removed,  or  partially  removed,  it  was 
found  to  be  not  a  cancerous,  but  a  cystic  tumor,  with  growths  from  the 
interior  surfaces  of  the  cysts.  She  remained  well  after  this,  the  wound 
having  perfectly  healed,  for  twelve  years  more,  and  in  this  interval  she 
ceased  to  menstruate ;  but  now,  when  she  was  fifty-five  years  old,  after 
having  a  whitlow  and  inflamed  lymphatics  of  the  right  arm,  another 
tumor  formed  in  the  breast,  which  had  every  appearance  of  being  can- 
cerous.    It  was  removed  ;  but  it  recurred,  and  ended  fatally. 

Now,  surely,  in  such  a  case  as  this,  we  may  say  that  all  the  local 
conditions  necessary  for  the  production  of  a  cancer  of  the  breast  had 
been  amply  provided.  They  had  existed,  or  had  been  reproduced  from 
time  to  time,  for  a  period  of  upwards  of  twenty  years  ;  yet  being  alone, 
they  had  been  insufficient ;  and  no  cancer  appeared  till  the  time  when, 
at  a  more  favorable  condition  of  age,  the  cancerous  condition  of  the 
blood  was  manifested,  and  filled  up  the  measure  of  the  necessary  pre- 
cedents of  the  disease. 

Contrast  with  the  cases  of  this  kind  those  to  which  I  had  occasion  to 
refer  in  a  former  lecture  (p.  584),  and  of  which  I  may  here  repeat  one: 
A  boy  received  a  cut  in  his  eye,  which  had  been  previously  sound. 
Within  three  weeks  of  the  injury  a  fungus  protruded  from  the  eye.  It 
was  removed  with  the  whole  eyeball  and  the  contents  of  the  orbit.  The 
wound  had  scarcely  healed  before  a  fresh  growth  appeared ;  and  shortly 
afterwards  the  boy  died  with  medullary  disease  extending  from  the 
orbit  to  the  brain.  We  can  scarcely  express  such  cases  as  this  in  any 
other  terms  than  that  the  cancerous  condition  of  the  blood  existed  at 
the  time  of  the  injury,  but  was  insufficient  for  the  production  of  a  can- 
cerous growth,  and  remained  latent,  for  want  of  an  appropriate  locality 
for  the  growth,  till  the  injury,  disturbing  or  causing  the  suspension  of 
the  natural  course  of  nutrition  in  the  part,  supplied  the  appropriate 
local  condition.  As  one  might  say,  the  seed  had  been  long  present  in 
the  blood,  but  the  soil  was  wanting,  and  the  injury,  hindering  or  divert- 
ing the  eye  from  its  ordinary  nutrition,  supplied  the  want,  and  prepared 
the  soil  for  the  growth  of  the  cancer. 

These  cases,  I  repeat,  are  but  examples  of  classes.  In  the  one  class 
we  seem  to  meet  with  all  the  constitutional  or  blood-conditions  of  can- 
cerous disease  complete,  waiting  only  for  the  existence  of  some  part  in 
which  the  cancerous  growth  may  be  manifested ;  in  the  other  class,  the 


672         LOCAL    AND    CONSTITUTIONAL    PREDISPOSITIONS. 

local  conditions  are  abundantly  present,  but  the  disease  does  not  appear 
till  the  cancerous  condition  of  the  blood  is  complete  (compare  p.  332). 
It  may,  further,  be  deduced  from  these  cases,  in  which  the  extremes 
illustrate  the  ordinary  mean,  that  if  either  of  the  two  conditions  be 
present  in  an  extreme  degree,  its  intensity  may  compensate  for  a  com- 
parative defect  of  the  other.  Among  the  cases  to  which  I  have  been 
referring,  we  find  certain  in  which  the  cancerous  disease  makes  its  ap- 
pearance in  such  a  multiplicity  of  growths  and  of  parts,  that  it  seems 
indifferent  to  local  conditions ;  and  these  are  the  very  cases  in  which 
all  the  other  constitutional  characters  of  cancer  are  most  strongly 
marked ;  in  which  cachexia  often  precedes  the  growth,  and  in  which 
the  removal  of  the  cancer  interferes  in  no  way  with  the  progress  of  the 
constitutional  disease,  unless  it  be  to  accelerate  it.  On  the  other  side, 
we  meet  with  cases  in  which  the  long-continued  irritations,  or  frequent 
injuries  of  certain  parts  of  the  body,  seem  almost  sure  to  be  followed 
by  cancer ;  and  these  are  the  cases  in  which  the  constitutional  charac- 
teristics of  the  disease  are  least,  marked,  and  in  which,  as  in  epithelial 
cancer  of  the  scrotum  and  of  scars,  we  may  hope  that  the  recurrence 
of  the  disease  may  be  long  deferred,  if  that  which  has  first  appeared  be 
removed  with  its  seat.  In  this  class  of  cases,  it  may  be  said,  the  can- 
cerous blood-condition  is  so  lowly  developed,  that  the  cancerous  growth 
can  ensue  in  none  but  a  peculiarly  appropriated  part,  which  part  being 
removed,  the  growth  is  for  a  time,  or  for  life,  impossible ;  while,  in  the 
former  class,  the  blood-condition  is  so  highly  developed,  or  so  intense, 
that  almost  any  part  sufiices  for  the  seat  of  growth. 

Let  me  now  proceed  to.  consider  what  each  of  these  conditions,  ne- 
cessary as  precedents  of  the  growth  of  a  cancer,  consists  in.  What  is 
the  cancerous  condition  of  the  blood  ?  and  what  is  the  state  of  a  locality 
apt  for  the  formation  of  a  cancerous  growth  ? 

I.  Concerning  the  state  of  the  blood,  our  positive  knowledge  is  very 
trivial  and  obscure ;  perhaps  it  would  be  safest  to  say  that  we  have  at 
present  none.  We  may  be  sure,  on  grounds  to  which  I  have  already 
referred,  that  there  is  a  peculiar  material  in  the  blood  which  is  separated 
from  it,  and  constantly  renewed,  in  the  formation  of  a  cancer ;  but  we 
can  say  what  this  material  is  not,  rather  than  Avliat  it  is. 

We  may  reasonably  hold  that,  in  cancerous  persons,  the  whole  con- 
stitution of  the  blood  is  not  perverted ;  for  we  see  that  all  the  tissues 
may  for  a  long  time  be  perfectly  nourished,  even  while  the  cancer  is 
making  progress;  that  injuries  may  be  repaired  with  the  ordinary  quick- 
ness and  perfection  ;  that  the  products  of  inflammation  may  be  like 
those  in  non-cancerous  persons,  and  may  pass  through  their  ordinary 
developments  ;  and  that  some  other  specific  diseases  may  have  their 
usual  course.  It  would  therefore  be  unreasonable  to  regard  the  whole 
of  the  blood  of  a  cancerous  person  as  perverted  from  its  normal  con- 
dition.    The  cancerous  state  is  not  a  total  change  of  the  blood,  but  de- 


GENERAL     PATHOLOGY    OF    CANCER.  673 

pends,  probably,  on  some  definite  material  mingled  Avith  the  natural 
constituents :  and  this  material,  we  may  believe,  is  derived  from  a  mor- 
bid transformation  of  one  or  more  of  the  natural  constituents  of  the 
blood,  and  is  maintained,  as  morbid  structures  are,  by  the  persistence 
of  the  same  method  of  transformation,  or  by  its  own  assimilating  force. 

But  now,  as  to  what  this  material  is ;  or,  again,  is  not.  I  believe  it 
is  not  anything  visible  to  the  sight.  There  is  not,  so  far  as  I  know, 
anything  in  the  blood  of  a  cancerous  person  which  we  can  recognize  as 
a  cancer-structure.  There  are  no  cancer-cells,  nor,  in  any  form,  visible 
germs  of  cancer,  existing  in  the  blood,  and  only  needing  to  be  separated 
from  it  to  make  up  or  grow  into  the  cancerous  structure.  In  advanced 
cases  of  cancer,  and  especially  in  those  in  which  the  cancerous  substance 
is  very  softened  and  broken,  we  may  meet  with  portions  of  it  in  the 
blood,  which  appear  as  if  they  had  been  detached  or  absorbed  from  some 
growth,  and  carried  on  with  the  stream.  In  similar  cases  we  may  find 
cancerous  formations  in  the  blood  itself.  Such  seem  to  be  some  of  the 
cancerous  growths  in  the  veins  and  the  right  side  of  the  heart.  For, 
although  among  the  former  there  are  many  in  which  the  growth  has 
only  extended  into  the  veins,  through  their  walls  involved  in  cancerous 
tumors,  yet  there  are  others  in  which,  as  in  the  endocardial  cancers,  the 
internal  growth  takes  place  far  from  any  other  tumor.  In  these  we 
may  believe  that  cancerous  structures  have  been  conveyed  in  the  blood 
to  the  part  of  the  vein,  or  of  the  right  side  of  the  heart,  at  which  they 
have  been  arrested,  and  to  which  adhering  (either  alone  or  with  blood- 
clot),  they  have  subsisted  and  grown  on  materials  derived  from  the 
passing  blood.  But  not  one  of  these  cases  affords  any  support  to  a 
belief  that,  previous  to  the  existence  of  a  cancerous  tumor,  any  visible 
germs  of  cancer  exist  in  the  blood. 

Other  means  for  investigating  the  very  nature  of  the  cancerous  mate- 
rial in  the  blood  seem  as  important  as  the  sight.  Minute  chemistry 
has,  up  to  this  time,  done  nothing;  neither  can  we  accept,  I  think,  that 
which  is  in  part  a  chemical  theory,  and  has  been  especially  held  by  the 
pathologists  of  the  Vienna  school, — namely,  that  particular  diatheses 
or  dyscrases  of  the  blood  appropriate  to  such  diseases  as  cancer  and 
tubercle,  may  be  recognized  by  a  superabundance  of  albumen  or  of 
fibrine.  The  facts  adduced  as  bearing  directly  on  these  doctrines  are, 
at  present,  few  and  incomplete ;  and  I  think  they  are  not  sufiicient 
either  to  establish  the  theories  based  on  them,  or  to  outweigh  the  gene- 
ral probability  that  diseases  so  complex  as  cancer  and  tubercle  should 
depend  chiefly  on  quantitative  variations  in  any  of  the  larger  constitu- 
ents of  the  blood.  Neither  can  it,  I  think,  in  the  present  state  of  or- 
ganic chemistry,  and  with  so  few  analyses  as  we  yet  possess  of  the  blood 
of  cancerous  and  other  diseased  persons,  be  more  than  a  guess,  that 
either  cancer  or  any  other  such  specific  disease,  depends,  in  any  sense, 
on  qualitative  modifications  of  the  albumen,  or  the  fibrine,  or  any  other 
single  constituent  of  the  blood. 


674  INCOMPATIBLE    DISEASES. 

At  present,  I  believe,  the  best  part  of  tlie  facts  established,  or  made 
probable,  by  these  investigations,  relate  to  the  antagonism  or  incom- 
patibility of  cancer  and  certain  other  specific  diseases.  I  think  we  can- 
not doubt  that,  as  a  general  rule,  cancerous  and  tuberculous  diseases  do 
not  make  active  progress  at  the  same  time  ;  and  that,  in  this  sense, 
they  exclude  one  another,  and  are  incompatible.  I  mentioned  in  a 
former  Lecture  (p.  549),  a  striking  case  bearing  on  this  point,  in  which, 
as  it  seemed,  the  rare  event  of  arrest  and  almost  complete  recovery 
from  scirrhous  cancer  was  connected  with  the  evolution  of  tuberculous 
disease.  I  believe,  also,  that  I  have  seen  at  least  one  instance  in  which 
active  tuberculous  disease  of  the  lungs  was  arrested  immediately  before 
the  appearance  of  a  scirrhous  cancer  in  the  breast :  and  we  find,  in  so 
many  of  those  who  die  with  cancer,  the  remnants  of  tuberculous  dis- 
ease from  which  they  have  suffered  in  earlier  life,  that  we  may  believe 
that  the  recovery  from  the  one  has  been  in  some  manner  connected  with 
the  supervention  of  the  other.  So,  on  the  other  side,  the  rarity  of  pro- 
gressive tuberculous  disease  in  those  that  are  cancerous  may  be  because, 
except  in  such  extremely  rare  cases  as  that  to  which  I  have  referred, 
the  cancerous  diathesis  excludes  that  condition  of  the  blood  in  which 
the  tuberculous  disease  has  its  rise. 

To  the  same  class  of  facts,  as  illustrating  the  exclusion  of  one  morbid 
condition  of  the  blood  (or,  as  Hunter  would  have  said,  of  one  morbid 
action),  by  another,  we  may  perhaps  refer  the  occasional  withering  of  a 
cancer  under  the  influence  of  some  fever,  and  the  more  rarely  occur- 
ring complete  death  of  one,  so  that  during  an  attack  of  acute  fever  the 
whole  mass  may  slough  ofl";  and  this  whether  the  feverish  condition  of 
the  blood  be  produced  by  some  miasma,  or  by  medicinal  means.  Such, 
I  fear,  is  all  that  can  be  at  j)resent  safely  regarded  as  matter  of  fact 
in  relation  to  the  nature  of  the  peculiarity  of  cancerous  blood ;  and  it 
must  be  admitted  that  these  facts  are  scarcely  more  than  indications  of 
the  direction  in  which  inquiry  should  be  made.  Let  us  next  see  if  we 
can  in  any  measure  trace  the  method  of  its  production ; — whence  the 
specific  material  is  derived  from  without,  and  the  conditions  most  favor- 
able to  its  generation  within,  the  body. 

First,  it  is  evident  that  a  disposition  to  cancer  may  be  derived  by 
inheritance ;  that  something  may  be  transmitted  from  the  parent  to  the 
offspring,  which  shall  utimately  produce  both  the  cancerous  condition 
of  the  blood  and  the  locality  apt  for  the  cancerous  growth. 

In  322  cancerous  patients,  there  were  78,  or  very  nearly  one-fourth, 
who  were  aware  of  cancer  in  other  members  of  their  families.  The 
proportion  is  much  larger  than  could  be  due  to  chance ;  and  its  import 
is  corroborated  by  the  fact  of  many  members  of  the  same  family  being 
in  some  instances  affected.* 

That  which  is  transmitted  from  parent  to  offspring  is  not,  strictly 

*  Medico-Chir.  Trans.,  vol.  xlv.,  op.  cit. 


GENERAL    PATHOLOGY    OF    CANCER.  675 

speaking,  cancer  or  cancerous  material,  but  a  tendency  to  tlie  produc- 
tion of  those  conditions  which  will,  finally,  manifest  themselves  in  a 
cancerous  growth.  There  are  here  some  facts  worth  dwelling  upon, 
both  for  their  own  sake,  and  because  they  are  clear  instances  of  the 
manner  in  which  the  hereditary  transmission  of  the  properties  of  the 
parent  body  takes  place. 

I  repeat,  that  which  is  transmitted  from  parent  to  offspring  is  not 
cancer  itself,  but  a  tendency  to  the  production  of  cancer  at  some  time 
far  future  from  the  birth.  We  have  no  reason  to  believe  that  a  cancer- 
ous material  passes  with  the  germ.  To  suppose  such  a  thing,  where  the 
cancerous  parent  is  the  male,  would  be  almost  absurd.  Moreover,  no 
reason  to  believe  that  cancerous  material  passes  from  either  parent  is 
furnished  by  any  frec^uency  of  congenital  cancer. 

But  while,  on  the  one  hand,  we  cannot  assume  that  a  cancerous  mate- 
rial passes  with  the  germ  or  impregnating  fluid ;  on  the  other,  we  can- 
not understand  the  transmission  of  a  tendency  or  disposition  to  any 
event,  independently  of  all  material  conditions.  The  germ  from  the 
cancerous  parent  must  be  already,  in  some  condition,  different  from  one 
from  a  parent  who  is  not  cancerous,  if,  in  the  course  of  any  number  of 
years,  cancers  are  to  be  formed  out  of  the  substance  which  the  germ,  in 
its  development,  or  subsequent  changes,  will  appropriate.  Our  ex- 
pression, then,  may  be,  that  in  the  impregnated  germ  from  a  cancerous 
parent,  one  or  more  of  the  materials,  normal  as  they  may  seem,  are 
already  so  far  from  the  perfectly  normal  state,  that  after  the  lapse  of 
years,  by  their  development  or  degeneration,  they  will  engender  or 
constitute  the  cancerous  material  in  the  blood,  and,  it  may  be,  the 
locality  apt  for  a  cancerous  growth. 

But  now  let  it  be  observed,  this  tendency  to  cancerous  disease  is 
most  commonly  derived  from  a  parent  who  is  not  yet  manifestly  can- 
cerous ;  for,  most  commonly,  the  children  are  born,  and  sometimes  even 
become  cancerous  before  cancer  is  evident  in  the  parent ;  so  that,  as 
we  may  say,  that  which  is  still  future  to  the  parent  is  transmitted  po- 
tentially to  the  offspring.  Nay,  more :  the  tendency  which  exists  in 
the  parent  may  never  become  in  him  or  her  effective,  although  it  may 
become  effective  in  the  offspring ;  for  there  are  cases  in  which  a  grand- 
parent has  been  cancerous,  and  although  his  or  her  children  have  not 
been  so,  the  grandchildren  have  been.  How  admirable  a  discovery  it 
would  be  if  we  could  find  the  means  by  which  the  tendency,  conveyed 
from  the  grandparent  to  the  child,  was  yet  diverted  from  its  course, 
even  after  it  had  been  transmitted  to  the  germ  of  the  grandchild  ! 

Let  me  repeat,  the  cases  of  hereditary  cancer  only  illustrate  the  com- 
mon rule  of  the  transmission  of  hereditary  properties,  whether  natural 
or  morbid.  Just  as  the  parent,  in  the  perfection  of  maturity,  trans- 
mits to  the  offspring  those  conditions,  in  germ  and  rudimental  sub- 
stance, which  shall  be  changed  into  the  exact  imitation  of  the  parent's 
self,  not  only  in  the  fulness  of  health  but  in  all  the  infirmities  of  yet 


676  HEREDITARY    TRANSMISSION. 

future  age  ;  so,  also  even  in  seeming  health,  the  same  parent  may  com- 
municate to  the  materials  of  the  offspring  the  rudiments  of  yet  future 
diseases ;  and  these  rudiments  must,  in  the  case  before  us,  be  such 
modifications  of  natural  compositions  as,  in  the  course  of  many  years, 
shall  be  developed  or  degenerate  into  materials  that  will  manifest  them- 
selves in  the  production  of  cancer. 

There  is,  surely,  in  all  science,  no  fact  so  strange  as  this :  and  it 
need  not  be  a  barren  fact,  fit  merely  for  wonder  and  vain  speculation  ; 
for  we  may  deduce  from  it  that  the  cancerous  substance  in  the  blood, 
whatever  it  may  be,  and  whencesoever  derived,  is  a  result  of  long-con- 
tinued elaboration ;  needing,  as  the  normal  materials  of  the  body  do,  to 
pass  through  a  life  of  continual  change  before  it  attains  its  complete 
efficiency.  The  period  required  for  this  completion  of  the  cancer-ma- 
terial, is  the  time  often  of  long  delay,  during  which  the  disease,  accord- 
ing to  various  expressions,  is  "latent,"  or  only  in  "predisposition." 
But  such  expressions  are  deceptive.  As  with  other  specific  blood-dis- 
eases, so  with  cancer,  the  predisposition  to  it  is  a  substantial  thing  ; 
and  we  should  hold  that,  in  all  the  time  of  latency,  there  is  that  thing 
in  the  blood  which  will  become,  or  generate  by  combination,  the  effec- 
tive cancer-material,  unless  (as  in  the  healthy  generation  between  the 
cancerous  grandparent  and  the  cancerous  grandchild)  it  be  destroyed 
or  retained  in  the  course  of  natural  nutrition. 

In  hereditary  transmission,  the  cancer-material  may  be  modified,  so 
that  the  form  of  the  disease  in  the  offspring  may  be  different  from  that 
in  the  parent.  The  change  from  scirrhous  to  medullary  cancer,  and 
vice  versa,  is,  I  believe,  not  rare.  I  have  mentioned  cases  of  alterna- 
tion between  these  and  the  epithelial  cancers  (p.  626) ;  and  a  case  of 
melanoid  cancer  in  a  patient  descended  from  one  with  a  scirrhous  breast 
(p.  641).  Mr.  Simon  has  told  me  that  he  removed  a  colloid  cancer 
from  the  cheek  of  a  woman,  whose  child,  seven  years  old,  was  dying 
with  medullary  cancer  of  the  eye ;  and  M.  Lebert,  with  two  cases  like 
these,  relates  that  the  celebrated  Broussais  died  with  medullary  cancer 
of  the  rectum,  and  his  son,  Casimir,  with  colloid  cancer  of  the  same 
part.  With  so  many  cases  supporting  it,  this  kind  of  transmutation 
during  transmission  of  cancer,  can  hardly  be  doubted.  But  I  believe 
we  may  trace  further  changes  in  the  transmission  ;  and  that  the  ma- 
terial may  be  so  altered  that,  as  we  may  say,  the  cancerous  disposition 
may  gradually  cease,  or  fade  out  in  the  production  of  tumors,  whose 
characters  are  intermediate  or  transitional  between  cancerous  and  sim- 
ple growths.  I  have  referred  (p.  491)  to  cases  illustrating  this  opi- 
nion ;  and  I  feel  sure  that  many  more  will  be  found ;  for  we  may 
observe  corresponding  changes  in  both  form  and  degree,  in  the  here- 
ditary transmission  of  many  other  diseases.  Thus  the  syphilis  of  the 
infant  is  seldom  exactly  like  that  of  the  mother ;  the  same  family  may 
include    cases  of  insanity,   epilepsy,  palsy,  chorea,   stammering,    and 


GENERAL  PATHOLOGY  OF  CANCER.  677 

other  diseases  allied  to  these  in  all  that  are  aifections  of  the  nervous 
centres,  but  differing  from  them  in  form  and  degree.* 

The  rule  of  hereditary  transmission  (a  rule  which,  like  many  in  patho- 
logy, has  more  seeming  exceptions  than  examples  (p.  326),  holds  for 
only  a  fourth  of  the  cases  of  cancer.  Can  we,  for  the  remainino-  three- 
fourths,  trace  any  external  source  of  the  morbid  condition  of  the  blood? 
Inoculation  and  contagion  are  the  only  probable  sources  of  the  kind ; 
but  concerning  these  the  presumed  facts  are,  at  present,  very  few  and 
uncertain.  There  are  cases  in  which,  by  the  inoculation  of  cancerous 
material  into  the  bodies,  or  by  the  injection  of  such  material  into  the 
blood  of  dogs,  cancer  has  seemed  to  be  produced.  I  think  that,  in  a 
large  number  of  experiments,  that  result  has  been  three  times  obtained  ; 
but  it  is  quite  possible  that  the  dogs  used  for  these  three  experiments 
were  cancerous  before  the  human  cancerous  matter  was  injected  into 
them  ;  for  cancer  is  indeed  a  frequent  disease  among  dogs.  The  in- 
stances are  certainly  too  few  for  proof  of  inoculation. 

There  are,  also,  certain  cases  in  which  it  seems  possible  that  cancer 
may  have  been  transmitted  from  the  wife  to  the  husband  during  the 
act  of  copulation.  Such  cases  are  recorded  by  Dr.  Watson  and  Dr. 
Copland  ;f  wives  having  cancer  of  the  uterus  had  husbands  with  cancer 
of  the  penis.  Of  course  it  must  be  questionable  whether  there  were  in 
these  cases  more  than  the  accidental  coincidence  of  persons  having  mar- 
ried, in  both  of  whom  an  ordinary  and  independent  generation  of  cancer 
ensued  ;  and  we  cannot  conclude  that  inoculation  of  cancer  may  thus 
occur,  unless  it  should  appear  that  persons  thus  related  become  cancer- 
ous in  larger  proportions  than  they  do  who,  being  otherwise  in  similar 
conditions,  are  not  thus  exposed  to  the  possibility  of  inoculation. 

Again,  I  have  heard  that  cancerous  matter  having  been  inoculated 
under  the  skin  of  frogs,  cancerous  growths  have  been  produced  in  them. 
I  have  repeated  this  experiment,  but  without  effect ;  for  all  the  frogs 
in  whom  I  inserted  the  cancerous  matter  died  soon  after.  But  the  facts, 
so  far  as  I  have  yet  heard  them,  have  not  much  meaning  in  relation  to 
the  general  pathology  of  can<3er ;  for  I  believe  it  is  not  yet  proved  that 
the  local  growths  of  cancer,  which  are  the  consequences  of  the  inocu- 
lation, are  followed  by  general  cancerous  disease,  or  by  the  production 
of  cancer  in  distant  parts,  as  well  as  in  that  in  which  the  matter  was 
deposited.  Unless  this  occurs,  the  experiments  only  prove  the  fact 
(and  a  very  strange  one  it  is)  that  materials  of  disease  from  human 
bodies,  being  inserted  in  the  bodies  of  cold-blooded  animals,  will  live 
and  grow,  even  upon  the  materials  of  the  cold-blooded  creature.  In 
like  manner,  if  any  one  could  establish  the  supposed  cases  of  husbands 
inoculated  by  their  wives,  he  might  only  prove  that  cancerous  elements 

*  Hereditary  malformations  display  similar  mutations  in  transitu  ;  as  in  instances  in  the 
Museum  of  St.  Bartholomew's,  Casts  A  21  to  27.  The  whole  of  this  subject  of  the  change  of 
diathesis  in  hereditary  transmissions  will  repay,  I  believe,  the  deepest  study. 

■f  Diet,  of  Pract.  Med. ;  Art.  Scirrhous  and  other  Tumors^ 


680  INFLUENCE  OF  CLIMATE. 

in  its  production,  we  must  consider  the  eifect  of  time  in  making  certain 
parts  apt  to  be  the  seat  of  cancer.  Such  an  effect  is  shown  in  the  dif- 
ferent liabilities  which  each  organ  manifests  at  different  periods  of  life. 
These  cannot  be  exactly  stated  ;  but,  beyond  doubt,  the  eye  and  orbit 
are  earliest  apt  to  become  cancerous  ;  then  the  bones,  testicles,  and  the 
areolar  tissue  of  the  limbs  and  trunk.  These  are  its  chief  seats  before 
30  years  of  age  ;  from  30  to  50  it  predominates  in  the  penis,  uterus, 
external  sexual  organs,  and  the  breasts ;  after  50,  in  the  integuments 
and  digestive  organs.*  I  fear  nothing  can  be  said  of  the  real  nature 
of  the  changes  ensuing  in  each  organ,  which  thus  make  it,  at  different 
times  of  life,  more  or  less  appropriate  for  the  seat  of  cancer.  In  some 
parts,  as  the  testicles  and  limbs,  the  chief  liability  seems  to  coincide 
with  the  first  attainment  or  Avith  the  time  of  failing  in  the  attainment 
or  maintenance,  of  full  functional  power  ;  in  others  it  falls  in  with  the 
beginning  of  the  loss  of  power,  as  in  the  uterus  and  breast. 

Two  other  conditions  seem  to  have  influence  in  producing  or  pro- 
moting the  cancerous  constitution  :  namely,  climate,  and  mental  dis- 
tress. Dr.  Walshe  has  collected  evidence  that  "  the  maximum  amount 
of  cancerous  disease  occurs  in  Europe,"  and  that  it  is  very  rare  among 
the  patients  of  the  hospitals  at  Hobart  Town  and  Calcutta,  and  among 
the  natives  of  Egypt,  Algiers,  Senegal,  Arabia,  and  the  tropical  parts 
of  America.  We  cannot,  indeed,  be  sure  that  this  difference  depends 
on  climate  ;  it  may  be  due  to  the  national  differences  in  habits  of  life  ; 
possibly,  as  Dr.  Walshe  suggests  (p.  160),  the  greater  prevalence  of 
cancer  may  be  due  to  the  more  wasting  influence  of  the  higher  state  of 
civilization.  More  records  are  necessary  to  decide  such  questions  ;  and 
it  may  be  well  if  they  include  accounts  of  the  apparent  variations  of 
cancer  among  nations  whose  climate  and  habits  of  life  are  not  mate- 
rially different.     (See  pp.  344,  421.) 

It  is  only  on  a  general  impression,  not  by  counted  facts,  that  we  can 
reckon  deep  mental  distress  among  the  conditions  favorable  to  the  pro- 
duction of  cancer.  I  do  not  at  all  suppose  that  it  could  of  itself  gene- 
rate a  cancerous  condition  of  the  blood ;  or  that  a  joyous  temper  and 
prosperity  are  a  safeguard  against  cancer ;  but  the  cases  are  so  fre- 
quent in  which  deep  anxiety,  deferred  hope,  and  disappointment,  are 
quickly  followed  by  the  growth  or  increase  of  cancer,  that  we  can 
hardly  doubt  that  mental  depression  is  a  weighty  addition  to  the  other 
influences  that  favor  the  development  of  the  cancerous  constitution. 
Nor  is  it  strange  that  it  should  be  so  ;  it  is  consistent  with  the  many 
other  facts  showing  the  affinity  between  cancer  and  depressed  nutrition. 

But,  after  all,  when  we  have  assigned  to  these  conditions  their  full 
weight  in  producing  the   cancerous  constitution  or  state  of  the  blood, 

*  More  rules  of  this  kind  may  perhaps  be  gathered  from  the  statistics  of  Walshe  and  Le- 
bert ;  but  with  caution,  for  want  of  such  records  as  I  have  said  are  necessary  to  estimate 
the  liabilities  of  the  sexes. 


GENERAL  PATHOLOGY  OF  CANCER.  681 

that  which  may  strike  us  most  of  all  is  the  comparatively  small  influ- 
ence which  any  known  internal  or  external  conditions  possess.  We 
are,  as  yet,  wholly  unaware  of  any  great  difference,  in  the  frequency 
of  cancer,  among  those  of  our  own  nation  who  are  most  widely  apart 
from  each  other  in  all  the  ordinary  conditions  of  life.  The  richest  and 
the  poorest  alike  seem  to  be  subject  to  it ;  so  do  the  worst-  and  the  best- 
fed  ;  those  that  are  living  in  the  best  conditions  of  atmosphere,  and 
those  that  are  immured  in  the  worst ;  those  that  are  cleanly,  and  those 
that  are  foul ;  those  of  all  temperaments,  and  of  all  occupations  (except 
such  as  have  peculiar  local  influences) ;  those  that  appear  healthy  and 
those  that  are  diseased,  except  those  with  some  few  specific  diseases. 
We  can  hardly  lay  our  hand  upon  any  one  of  the  various  circumstances 
of  life,  in  the  various  orders  of  society  in  this  country,  to  which  we  can 
refer  as  rendering  one  more  or  less  liable  than  another  to  the  acquire- 
ment of  the  cancerous  constitution.  Dr.  Walshe's  evidence  amply  shows 
the  want  of  foundation  of  all  the  general  impressions  opposed  to  this 
conclusion. 

From  this  confession  of  ignorance  respecting  the  production  of  the 
cancerous  constitution,  or,  as  I  would  say,  of  the  cancer-material  in 
the  blood,  when  it  is  generated  within  the  body,  I  will  proceed  to  speak 
of  some  of  the  changes  which,  being  once  generated,  it  may  undergo. 

In  all  ordinary  events  the  normal  course  of  cancerous  disease  is  that 
of  steady  progress  towards  death.  The  increase  is  indicated  by  two 
difi"erent,  but  usually  commensurate,  series  of  phenomena :  those, 
namely,  of  increasing  formation  of  cancer-structures,  and  of  increas- 
ing cachexia. 

We  may  commonly  observe,  that,  from  the  beginning  of  a  cancerous 
formation,  there  is  a  constant  increase  in  its  mass,  and  in  the  rate  at 
which  it  is  added  to.  Even  the  cancers  that  are,  in  part,  ulcerating, 
are  usually  growing,  at  a  greater  rate,  at  the  border  or  surface  opposite 
to  that  in  which  ulceration  is  destroying  them ;  or  else,  while  ulcera- 
tion is  going  on  in  one  cancer,  there  is  a  greater  rate  of  increase  in 
others  ;  or,  the  number  of  growing  masses  is  constantly  increasing.  In 
one  or  more  of  these  methods  most  cases  exemplify  the  general  rule, 
that  the  quantity  of  cancer  which  is  formed  within  any  given  length  of 
time,  regularly  increases  from  the  beginning  to  the  end  of  the  case. 

In  most  cases  the  increasing  formation  of  cancer  is  accompanied  by 
manifest  indications  of  increasing  cachexia.  But  it  is  not  always  thus ; 
in  a  large  number  of  cases,  especially  of  cancers  of  external  organs, 
no  cachexia  appears  till  the  local  disease  has  made  great  progress  ;  and, 
on  the  other  hand,  we  find  cases,  especially  of  internal  cancers,  in 
which  the  cachexia  increases  without  proportionately  increasing  can- 
cerous formations :  cases  in  which  we  may  say  that  the  cancerous  con- 
dition of  the  blood  manifests  itself  less  plainly  in  the  production  of 
growths,  than  in  its  interference  with  the  ordinary  phenomena  of  life. 
Such  cases  are  not  unfrequent  among  those  of  cancer  of  the  rectum  : 

44 


682  INCREASE    OP    DIATHESIS. 

we  see  the  patient  intensely  ill,  and  dying  with  cachexia,  to  which  the 
extent  or  rate  of  growth  of  the  cancerous  tumor  bears  no  proportion. 
So,  sometimes,  with  cancer  of  the  liver ;  the  cachexia  is  quite  dispro- 
portionate to  the  amount  of  cancerous  formation,  and  to  the  degree  in 
which  it  interferes  with  the  functions  of  the  organ.  In  these  cases,  the 
cancerous  disease  exemplifies  a  frequent  event  in  the  history  of  specific 
diseases  :  namely,  that  when  the  morbid  material  is  most  intense  and 
acute  in  its  action,  when  it  most  manifestly  afi'ects  the  constitution,  it 
may  produce  the  least  indications  of  local  morbid  influence. 

In  both  these  sets  of  cases,  the  increase  of  cancerous  disease,  and 
its  accelerating  rate,  are  illustrated  as  the  rule  of  its  career.  The  phe- 
nomena, in  the  first  set  of  cases,  may  be  explained  by  assuming  that 
the  quantity  of  cancer-material  in  the  blood  regularly  increases ;  those 
in  the  second,  that,  with  its  increase,  it  undergoes  some  transformation, 
rendering  it  less  appropriate  for  growths,  but  more  injurious  to  the 
other  ofl&ces  of  the  blood. 

[b)  The  cancerous  constitution  may  apparently  cease ;  a  growth  al- 
ready formed  may  maintain  itself,  subsisting,  probably,  on  the  normal 
constituents  of  the  blood,*  but  its  progressive  increase  may  be  for  a 
time  suspended.  I  have  exemplified  this  by  cases  of  medullary  cancer 
(p.  586),  of  which  the  general  history  was,  that,  after  a  certain  period 
of  increase,  the  tumors  ceased  to  enlarge,  were  for  a  time  stationary 
(the  general  health  also  remaining  the  same),  and  then  resumed  the 
cancerous  mode  of  progress. 

(c)  The  cancerous  constitution  may  be  in  some  measure  changed  or 
modified.  It  may  manifest  itself  for  a  time  in  a  certain  form  of  cancer, 
and  then  in  some  other  form.  Thus  scirrhous  cancer  may  be  succeeded, 
in  secondary  growths,  by  medullary  cancer ;  osteoid  by  medullary,  and 
vice  versa  ;  and,  I  think,  epithelial  by  medullary.  We  must,  I  believe, 
in  these  cases  assume  a  transformation  of  the  specific  cancerous  mate- 
rial in  the  blood, — a  change  corresponding  with  that  which  may  be 
more  regularly  traced  in  the  materials  of  other  specific  diseases  {e.  g., 
of  syphilis)  in  their  successive  stages  or  periods  of  life  (pp.  327,  333). 

Lastly,  the  cancerous  diathesis,  even  after  it  has  been  manifested  by 
growths,  may  be  superseded.  Thus,  we  may  express  the  cessation,  or 
retrocession,  of  cancer,  when  tuberculous  disease  ensues  in  its  course. 

In  the  last  three  events  the  rule  of  progress  in  cancer  is  departed 
from.  But  if  we  could  reckon  all  the  cases  in  which  any  of  these 
events  happen,  they  would  make  but  a  few  exceptions  to  the  general 
rule,  that  the  cancerous  constitution  regularly  increases  at  an  accele- 
rating rate,  and  with  little  change  in  its  methods  of  manifesting  itself. 

*  I  shall  revert  to  this  point  in  the  next  Lecture.  The  maintenance,  or  even  the  increase, 
of  a  cancerous  growth,  does  not  necessarily  imply  that  a  cancerous  condition  of  the  blood  is 
maintained :  once  formed,  a  cancer,  like  any  other  tumor,  may  live  and  grow  by  its  assimi- 
lative power  over  cancerous  materials. 


GENERAL  PATHOLOGY  OF  CANCER.  683 

I  pass  now  to  the  consideration  of  the  second  necessary  precedent 
of  a  cancerous  growth,  namely,  the  existence  of  some  part  fitted  to  be 
its  seat — some  apt  locality.  Such  fitness  may  be  natural  or  acquired  ; 
and  in  parts  in  which  it  is  in  some  measure  natural,  it  maybe  increased 
by  accident  or  disease. 

Certain  parts  of  the  body  are  evidently,  and  independently  of  ex- 
ternal influences,  far  more  liable  than  others  are  to  become  the  seats 
of  cancer.  They  are,  thus,  naturally  apt  localities  ;  not  equally  so 
throughout  life,  but  usually  becoming  so  at  certain  periods. 

We  have  no  such  full  and  impartial  statistical  evidence  as  might 
enable  us  to  state  clearly  the  proportions  in  which  the  several  organs 
are  primarily  or  secondarily  affected  with  cancer.  There  are  at  pre- 
sent, I  believe,  no  large  statistics  on  which  we  can  place  reliance  for 
accurately  determining  this  point ;  bills  of  mortality,  founded  upon  di- 
agnoses not  confirmed  by  autopsy,  and  the  records  of  those  whose  prac- 
tice is  chiefly  medical  or  chiefly  surgical,  supply  only  unsafe  or  partial 
evidence. 

It  cannot  be  doubted  that  the  uterus,  stomach,  and  female  breast 
hold  the  first  place  in  aptness  for  primary  cancerous  growths ;  and  the 
lymphatics,  lungs,  and  liver,  for  secondary  growths  ;  and  that  among 
the  parts  least  liable  to  either  aff"ection  are  the  spinal  cord,  tendons, 
tonsils,  pharynx,  and  prostate  gland.  But  beyond  these  general  state- 
ments none,  I  think,  can  be  safely  made.  Neither  does  any  explana- 
tion yet  offered  of  the  difi'erent  liabilities  of  parts  seem  well  founded. 
As  Dr.  Walshe  observes,  all  that  has  been  said  to  explain  the  lia- 
bility of  the  breast  and  uterus  may  be  equally  well  said  of  the  ovaries, 
which  are  comparatively  rarely  cancerous.  So,  too,  what  has  been 
said  about  the  brain  and  stomach,  and  testicle,  is  just  as  applicable  to 
the  spinal  cord,  the  duodenum,  and  the  epididymis  ;  yet  these  parts  of 
similar  systems  are,  severally,  in  complete  contrast  in  their  aptness  to 
be  the  seat  of  cancer. 

It  seems  impossible,  at  present,  to  discover  what  it  is  that  makes 
one  part  more  than  another  naturally  fit  to  be  the  seat  of  cancerous 
growth  ;  or  any  part  more  fit  at  one  time  of  life  than  at  another.  We 
are,  of  course,  disposed  to  look  for  explanation  to  peculiarities  of  tissue, 
and  to  their  changes  with  age  ;  and  we  can  hardly  doubt  that  these 
are  chiefly  influential :  and  yet,  as  the  medullary  cancers  of  the  eye- 
ball and  orbit  show  (p.  577),  we  must  ascribe  something  to  locality  as 
well  as  to  tissue.  The  allocation  of  cancers  is  certainly  not  wholly 
determined  by  aptness  of  structures.  An  osteoid  cancer,  for  example, 
affects  at  once  cancellous  and  compact  osseous  tissue,  medulla,  perios- 
teum, and  surrounding  muscles  ;  a  medullary  cancer  may  occupy,  from 
the  first,  many  tissues  both  within  and  around  the  eyeball :  when  a 
cancerous  breast  is  cut  away,  the  recurrent  growths  appear  very  com- 
monly in  the  scar,  i.  e.  in  the  same  locality,  though  all  the  tissues 
affected  by  the  primary  growth  are  gone.     Very  numerous  cases  such 


684  LIABILITY    OF    CERTAIN     PARTS. 

as  these  might  he  cited ;  they  cannot,  I  presume,  he  explained,  hut 
they  suggest  the  need  of  considering  always  that  morbid  products  may 
he  determined  to  certain  places  as  well  as  to  certain  structures.  As 
each  natural  organ  has  its  appropriate  place  as  well  as  structure,  so, 
hut  with  almost  infinitely  less  regularity,  morhid  growths  may  have 
laws  of  allocation. 

A  question  of  much  interest  is  connected  with  the  liahility  of  other 
tumors  to  become  cancerous  ;  it  is  of  interest  not  only  as  a  subject  of 
pathological  inquiry,  but  in  relation  to  an  opinion  which  is  often  made 
a  reason  for  operations :  namely,  that  if  a  tumor  of  any  kind  is  left  to 
its  own  course,  it  is  not  unlikely  to  become  cancerous.  I  have  looked 
carefully  into  this  question,  and  I  believe  there  are  no  facts  sufficient 
to  justify  the  opinion  that  an  innocent  tumor  is  more  likely  to  becoine 
the  seat  of  cancer  than  many  other  parts  of  the  body  in  which  it  is 
growing.  The  only  case  supporting  such  an  opinion  is  that  of  cystic 
disease  of  the  ovary.  I  think  there  is  no  doubt  that  it  is  not  unfre- 
quent  for  cysts  of  the  ovary  to  'exist,  for  a  time,  as  an  innocent  disease, 
and  then  become  the  seat  of  cancerous  growths.  But  then,  the  case 
of  cystic  disease  of  the  ovary  is  so  peculiar  in  all  respects,  that  we 
cannot  deduce  from  it  any  rule  to  be  applied  to  instances  of  other 
tumors. 

With  regard  to  the  supposed  transformation  of  any  other  tumors  into 
cancers,  the  facts  are  very  few. 

M.  Lebert  states  that  he  has  twice  met  with  tumors  which  were  at 
first  of  an  innocent  kind,  but  afterwards  became  cancerous  ;  but  he  does 
not  state  whether  they  were  in  persons  who  had  cancer  in  some  other 
part :  i.  e.  whether  the  cancer  in  the  tumor  were  secondary  or  primary. 

Sir  Benjamin  Brodie  mentions  a  case  in  which  he  removed  a  tumor, 
the  general  mass  of  which  appeared  to  be  fatty  substance,  somewhat 
more  condensed  than  usual,  but  "  here  and  there  was  another  kind  of 
morbid  growth,  apparently,  belonging  to  the  class  of  medullary  or  fun- 
goid disease."*  A  few  other  cases  of  the  same  kind  are  related;  and 
some  would  assume  that  in  all  the  cases  of  mixed  cartilaginous  and  can- 
cerous tumors  (mentioned  at  p.  459)  the  cartilaginous  growth  was  being 
transformed  into,  or  superseded  by,  the  cancerous  one.  I  see  no  good 
evidence  for  such  an  assumption  :  the  contrary  might  very  well  be 
maintained  in  argument ;  or  the  two  growths  might  be  regarded  as 
simultaneous  in  their  origin. 

It  need  not  be  denied  that  cancerous  growths  may  occur  in  tumors 
that  were  previously  of  an  innocent  kind,  but  I  feel  quite  sure  that 
these  may  be  regarded  as  events  of  the  greatest  rarity. 

My  own  experience  has  (perhaps  by  chance)  been  such  as  would  in- 
dicate that  innocent  tumors  are  less  liable  to  cancer  than  the  structures 
they  resemble ;  for,  as  I  have  elsewhere  mentioned  (p.  491),  I  have 

*  Lectures  on  Pathology  and  Surgery,  p.  282. 


EFFECTS  OF  INJURY  AND  DISEASE.  685 

seen  three  cases  in  which  cancer  affected  the  natural  structure  of  the 
mammary  gland,  while,  close  by,  mammary  glandular  tumors  remained 
unaffected. 

It  may  be  asked,  whence  is  derived  the  impression  that  so  commonly 
exists,  that  a  tumor  of  an  innocent  kind  is  peculiarly  apt  to  become 
cancerous  ?  I  believe  it  has  arisen  from  several  different  kinds  of  de- 
ceptive cases. 

First,  there  are  the  cases  of  what  I  have  referred  to  as  the  suspen- 
sion, for  a  time,  of  cancerous  progress ;  in  these  the  cancer  seems  for  a 
time  to  be  an  innocent  tumor ;  it  is  judged  to  be  so  because  it  remains 
so  long  quiet ;  and  when  it  assumes  the  ordinary  progress  of  cancer,  it 
is  said  to  be  a  tumor  once  innocent,  but  now  become  cancerous.  This 
might  have  happened  in  the  first  and  fourth  of  the  cases  mentioned  at 
p.  586 ;  yet,  without  doubt,  in  these  cases,  the  tumors  that  made  little 
or  no  progress  had  all  along  the  cancerous  structure. 

Another  class  of  deceptive  cases  have  a  history  of  this  kind  :  A  tu- 
mor is  removed  which  is  apparently  of  an  innocent  sort ;  but,  some 
time  after,  a  cancer  appears  at  the  same  part.  The  explanation  of  some 
of  these  cases  is  (as  I  suggested  on  p.  491),  that  a  simple  tumor  has 
grown  in  a  person  having  an  hereditary  or  other  constitutional  ten- 
dency to  cancer ;  and  that,  in  the  removal  of  this  tumor,  the  surgeon 
has  unwittingly  supplied,  by  the  local  injury,  what  was  needed  for  the 
production  of  a  cancerous  growth ;  he  has  made  some  locality  apt  for 
the  manifestation  of  a  constitutional  disease  already  existing. 

In  a  third  class  of  cases,  we  may  find  in  the  same  person  a  succes- 
sion of  tumors,  of  which  the  first  may  have  few  or  no  characters  of  can- 
cer, and  the  last,  as  if  by  gradual  change,  may  be  evidently  cancerous.  I 
have  referred  to  this  in  connection  with  recurrent  tumors  (p.  510) ;  but 
the  facts  have  little  bearing  on  the  question  whether  an  innocent  tumor 
can  become  cancerous  ;  for  here  the  transition  is  effected,  not  in  one 
tumor,  but  in  a  succession  of  tumors. 

By  cases  such  as  these,  we  may,  I  believe,  explain  away  the  grounds 
for  the  assumption  that  simple  or  innocent  tumors  are  parts  peculiarly 
apt  to  become  cancerous.  Cancers  may  grow  in  such  tumors,  but  the 
event  is  so  rare,  that  it  cannot,  in  any  given  case,  be  reasonably  anti- 
cipated. 

It  remains  to  consider  how  parts  may  acquire  an  aptness  for  cancer- 
ous growth  in  them,  or,  in  most  instances,  how  that  aptness  which  they 
naturally  possess  may  be  increased ;  for  it  is  very  observable  that  the 
"exciting  causes"  of  cancer  act  with  far  greatest  effect  on  the  parts 
which  are,  without  their  help,  most  liable  to  it. 

Three  chief  conditions  may  be  here  enumerated  :  namely,  the  results 
of  certain  diseases  in  intra-uterine  life,  indicated  by  congenital  defect ; 
the  results  of  certain  diseases  after  birth  ;  the  consequences  of  injury. 

The  aptness  for  cancer  due  to  congenital  defect  is  exemplified  in  the 
peculiar  liability  of  moles  or  pigmentary  nsevi  to  become  the  primary 


686  GENERAL  PATHOLOGY  OF  CANCER. 

seats  of  melanosis.  I  have  already  enlarged  on  this  (p.  643),  and  have 
suggested  that  these  defects,  which  we  can  easily  see,  may  be  only  ex- 
amples of  a  larger  group  which,  though  invisible,  are  not  less  efficient 
in  rendering  certain  parts  peculiarly  liable  to  cancer. 

The  aptness  due  to  diseases  after  birth  may  be  illustrated  by  the 
liability  of  the  incrusted  warts  and  scars,  and  other  morbidly  changed 
parts,  to  become  the  primary  seats  of  epithelial  cancers.  For  other 
than  epithelial  cancers  the  effect  of  disease  in  disposing  parts  to  cancer 
is  slight.  We  find  no  remarkable  liability  in  parts  that  have  been 
changed  by  inflammation,  whether  of  common  or  specific  kind.  Few 
theories,  I  think,  have  been  less  founded  than  those  which  have  re- 
garded scirrhous  or  medullary  cancer  as,  in  any  sense,  the  result  or 
sequence  of  inflammation.  Parts  that  have  been  the  seats  of  inflamma- 
tion may  become  the  seats  of  cancer ;  but  I  doubt  whether  the  propor- 
tion in  which  they  do  so  be  much  greater  than  that  in  which  they 
become  cancerous  when  apparently  healthy. 

The  influence  of  injuries  is  more  evident.  About  a  fifth  of  those  who 
have  cancer  ascribe  it  to  injury;  and  although,  doubtless,  some  of  these 
are  wrong  in  their  belief,  yet,  among  the  rest,  there  are  some  in  whom 
the  consequence  of  injury  is  too  evident  to  admit  of  doubt.  But  here 
a  distinction  must  be  made  as  to  the  manner  in  which  injury  promotes 
the  production  of  cancers. 

In  certain  cases  the  cancerous  growth  appears  immediately  after  the 
common  effects  of  the  injury.  A  person  receives  (suppose)  a  blow,  and 
when  its  direct  effects  are  passing  away,  a  cancer  appears  in  the  in- 
jured part.  I  have  cited  cases  of  this  kind  in  the  history  of  medullary 
cancers  (p.  584) ;  among  which,  indeed,  the  event  seems  more  frequent 
than  among  those  of  other  forms. 

In  other  and  more  usual  cases,  a  much  longer  interval  passes  between 
the  injury  and  the  appearance  of  the  cancer.  The  injured  part  seems 
to  recover  without  change  of  structure.  In  most  cases,  indeed,  such  as 
those  of  ordinary  blows  on  the  breast,  the  direct  effects  of  the  injury 
are  not  such  as  we  might  expect  to  be  followed  by  structural  change, 
yet  doubtless,  the  part  remains  different  from  what  it  was. 

In  a  third  class  of  cases,  which  are  most  frequently  exemplified  in 
the  epithelial  cancers,  the  injuries  appear  to  be  ineffective  unless  they 
are  repeated  time  after  time,  so  as  to  produce,  we  may  suppose,  a  real 
change  of  structure  in  the  part  that  at  length  becomes  the  seat,  of 
cancer  (p.  627). 

It  is  important  to  remember  these  different  relations  between  in- 
juries and  the  growth  of  cancers,  not  only  for  pathology's  sake,  but  for 
practice. 

It  is  often  stated,  as  a  rule,  that  those  cancers  are  least  likely  to 
return  (it  should  be  said,  to  return  quickly),  after  removal,  which  have 
followed  the  seat  of  injury,  or  some  previous  disease  in  the  part.  Now, 
this  is  only  partially  true ;  it  is  probably  often  true  of  the  epithelial 


QUESTION    OF    CANCEROUS    TRANSFORMATION.  687 

cancers  that  have  grown  in  the  seats  of  repeated  injury,  of  frequent 
ulceration,  and  the  like ;  but  I  know  no  facts  relating  to  scirrhous  and 
medullary  cancers  that  will  support  it ;  and  I  believe  that  the  cases  in 
■which  cancers  follow  quickly  after  accidental  injury  are  just  those  in 
which  a  speedy  return  paay  be  anticipated  after  operations.  The  growth 
of  a  cancer  immediately  after  an  injury  implies  the  existence  of  an  in- 
tense cancerous  diathesis,  which  no  removal  of  the  cancer  is  likely  to 
affect ;  but  when  a  part  has  been  repeatedly  injured,  and  only  at  length 
becomes  the  seat  of  cancer,  it  implies  such  a  low  degree  or  state  of 
cancerous  diathesis,  as  we  may  expect  to  remain  long  "latent"  if  the 
slowly-prepared  locality,  with  all  that  has  grown  in  it,  be  cleanly  re- 
moved. Of  the  intermediate  cases,  in  which  some  clear  time  intervenes 
between  the  injury  and  the  growth  of  the  cancer,  we  must  hold,  I  think, 
that  the  abiding  effects  of  the  injury  keep  the  part  in  a  state  peculiarly 
apt  for  the  growth,  till  the  constitutional  condition  is  established.  This 
being  complete,  the  removal  of  the  growth  cannot  change  it ;  and  the 
injury  done  by  the  operation  would  be  enough  to  prepare  a  place,  if 
none  else  were  appropriate,  for  a  recurrent  cancer. 


LECTURE   XXXV. 

GENEEAL  PATHOLOGY  OF  CANCEE. 

PART  II. 

STRUCTURE    AND    LIFE    OF    C^.NCEROUS    GROWTHS. 

I  ENDEAVORED  to  illustrate,  in  the  last  Lecture,  those  two  conditions 
which,  judging  from  the  general  history  of  cancers,  and  the  analogy  of 
other  specific  diseases,  we  must  assume  as  necessary  precedents  of  a 
cancerous  growth  :  namely,  the  cancerous  diathesis,  constitution,  or 
morbid  condition  of  the  blood,  and  the  condition  of  some  part  appro- 
priate for  the  growth.  Now,  according  to  the  same  analogy,  the  as- 
sumed cancer-material  in  the  blood,  if  it  cannot  be  removed  by  any 
natural  excretory  organ,  will  determine  the  formation  of  some  abnor- 
mal organism  in  which  itself  may  be  incorporated ;  and  this  organism 
will  have  a  specific  structure  and  mode  of  life  significant  of  its  origin. 
It  is  of  these — the  general  structure,  composition,  and  life  of  cancerous 
growths — that  I  shall  now  speak. 

It  may  be  generally  held  that  the  characteristic  structures  of  a  can- 
cer  are  altogether  of  new  formation.     But  questions  are  often  raised 


GENERAL  PATHOLOGY  OF  CANCEE. 

whether  natural  structures  may  not  be  transformed  into  cancerous  ; 
or,  whether  cancerous  materials  may  not  be  simply  transferred  from 
the  blood  into  the  natural  textures  ;  or,  whether  natural  structures  can 
assume  cancerous  properties.  I  believe  such  questions  may  be  thus 
answered : 

(1)  It  is  not  probable  that  any  structure,  once  completely  formed, 
can  be  transformed  into  any  other.  Structures  may  change  by  de- 
generation ;  but  in  this  their  changes  are  as  limited  and  as  normal  as  in 
development.  The  instances  in  which  natural  or  other  structures  are 
supposed  to  become  cancerous  are,  chiefly,  those  in  which  new-formed 
cancer-structures  are  inserted  or  infiltrated  among,  or,  sometimes, 
within,  those  of  the  affected  part.  Of  such  cases  we  may  say  that  the 
part  becomes  the  seat  of  cancer  ;  not  that  it  becomes  cancerous. 

(2)  It  is  possible  that,  in  the  mutation  of  structures  effected  in  the 
nutrition  of  certain  parts,  the  elemental  structures  successively  formed 
may  gradually  assume  the  appearance  and  properties  of  those  of  can- 
cer. It  has  often  been  observed,  in  cases  of  cancer  of  the  liver,  that 
every  gradation  of  structure  appears,  from  the  natural  to  the  cancer- 
ous ;  and  that,  among  the  microscopic  structures,  are  many  of  which  it 
is  hard  to  say  whether  they  be  hepatic  cells  or  cancer-cells.  It  may 
be  that  this  only  exemplifies  the  tendency  of  cancer-structures  to  be 
conformed,  in  some  measure,  to  those  of  the  adjacent  natural  parts  ; 
but  it  may  also  be,  that  both  the  fact  and  this  well-known  tendency 
are  evidences  that  cancerous  properties  may  be  gradually  imparted  to 
the  elementary  structures  in  a  part,  so  that  as  they  are  successively 
formed  they  may  gradually  assume  more  of  the  characters  of  cancer. 
In  other  words,  as  in  inflammations  we  observe  the  wider  deviations 
from  the  normal  methods  of  nutrition  or  secretion,  the  larger  the  pro- 
portions are  in  which  the  inflammatory  exudation  is  mingled  with  the 
normal  products  of  the  part  (p.  241) ;  so,  it  may  be,  increasing  quanti- 
ties of  cancerous  material,  added  to  the  natural  elements  of  the  tex- 
ture, may  be  represented  by  successive  gradations  of  structure.  I 
cannot  doubt,  therefore,  that  transformation  into  cancer  is,  in  this  sense, 
possible. 

(3)  It  is  possible  that  undeveloped  cancer-material  may  be  separated 
from  the  blood,  with  the  materials  of  natural  excretory  organs,  and  may 
be  for  a  time  incorporated  with  the  transient  structures  of  such  organs. 
We  may  assume  this  from  the  analogy  of  the  cases  in  which  we  believe 
that  other  specific  morbid  materials  are  thus  eliminated  from  the  blood, 
as  well  as  of  the  cases  in  which  certain  materials,  which  should  be  sepa- 
rated from  the  blood  by  appropriate  organs,  are,  when  the  office  of  those 
organs  is  hindered,  vicariously  eliminated  by  others.  In  both  these 
cases  we  believe  that  alien  materials  are,  for  a  time,  incorporated  in  the 
structures  of  the  eliminating  glands,  and  then  discharged ;  and  it  is,  in 
like  manner,  possible  that  cancer-materials,  though  their  ordinary  ten- 


QUESTION  OF  CANCEROUS  TRANSFORMATION. 


689 


dency  is  to  determine  the  formation  of  peculiar  structures  for  their  in- 
corporation, may  be  incorporated  in  those  of  natural  glands.* 


*  From  numerous  observations  made  during  the  last  few  years,  it  would  appear  that  the 
characteristic  cancer-cells  and  nuclei  may,  like  the  corpuscles  of  pus,  take  their  rise  from  the 
pre-existing  cells  and  nuclei  of  the  texture  or  organ  in  which  the  new  growth  originates. 
This  mode  of  origin  of  the  structural  elements  of  cancer  was  first  pointed  out  by  Virchow, 
and  he  has  more  particularly  directed  attention  to  the  changes  which  take  place  in  the  con- 
nective tissue  during  the  development  and  growth  of  cancer  in  it.  This  process  he  has 
illustrated  and  described  in  carcinoma  of  the  breast,  in  Lecture  XIX  of  his  Cellular  Patho- 
logie.  From  these  observations,  it  would  appear  that  the  formation  of  well-defined  cancer- 
structures  is  preceded  by  definite  changes  in  the  corpuscles  of  the  connective  tissue  of  the 
part.  Their  nuclei  divide  and  increase  in  number  ;  the  corpuscles  themselves  swell  out  so 
as  to  be  accommodated  to  the  increased  endogenous  development  of  the  nuclei:  the  cor- 
puscles may  then  divide,  and  this  division  mg.y  take  place  in  such  a  way  as  to  form  rows 
of  small  young  cells  in  the  spots  where  normally  only  one  corpuscle  existed.  By  the  per- 
sistence of  this  process,  groups  of  new  cells  are  produced,  which  gradually  assume  the  ap- 
pearance of  cancer-cells.  These  are  contained  in  loculi  or  spaces,  the  boundaries  of  which 
are  formed  by  the  fibrous  element  of  the  connective  tissue.  Changes  of  a  closely  corres- 
ponding nature  in  a  case  of  carcinoma  ventriculi  have  been  figured  and  described  by  Fors- 
ter  in  his  Atlas  (Taf.  xxvii.  Fig.  2). 

It  is  not,  however,  in  the  connective  tissue  only  that  the  development  of  the  cancer-cells 
from  the  normal  textural  elements  has  been  traced.  In  the  muscular  fibre  also,  distinct  and 
satisfactory  evidence  has  been  obtained.  C.  0.  Weber  (Virchow's  Archiv,  xv,  pi.  xi)  has 
furnished  excellent  illustrations  of  it  in  cases  of  scirrhous  and  epithelial  cancer  of  the  tongue 
and  lips,  and  Dr.  Neumann  (Ibid.,  xx,  p.  152)  has  demonstrated  the  same  in  the  pectoralis 
major,  in  a  case  of  hard  cancer  of  the  breast. 

The  editor  has  also  had  excellentopportunitiesof  following  out  the  process  in  the  muscles 
of  a  man,  the  whole  of  whose  scapula,  with  its  proper  muscles,  Mr.  Syme  excised  for  a  large 
soft  cancerous  tumor,  involving  the  glenoid 

fossa  and  neck  of  the  bone,  and  the  muscles  Fig.  115. 

connected  with  its  dorsal  and  ventral  aspects. 
In  many  of  the  muscular  fibres  the  well- 
known  changes  of  structure  produced  by 
fatty  degeneration  were  seen ;  but  in  others, 
especially  after  the  addition  of  acetic  acid, 
changes  of  another  character  could  be  dis- 
tinctly traced.  In  some  of  these  commencing 
division  of  the  nuclei  was  observed  ;  in  others 
this  division  had  gone  on  to  a  much  greater 
extent,  so  that  where  but  a  single  nucleus 
had  originally  existed,  now  numbers  might 
be  seen.  And  these  were  arranged  either  in 
long  rows,  some  of  which  were  situated  close 
to  the  edge   of  the   fibre,  others   more  in  its 

substance,  or  else  were  clustered  together  in  irregular  groups  (a,  Fig.  115).  In  many  spe- 
cimens both  the  linear  and  clustered  arrangements  could  be  seen  in  the  same  fibre,  and 
when  these  were  largely  developed,  all  trace  of  the  transverse  striae  had  disappeared,  and 
the  fibre  was  completely  filled  with  young  brood  (b).  A  still  further  stage,  evidently  indi- 
cating disintegration  of  the  fibre,  was  also  noticed  in  many  of  these.  Their  regular  outlines 
no  longer  existed,  and  instead,  they  possessed  a  jagged  appearance  as  if  breaking  up,  and 
adding  their  quota  of  contained  structures  to  the  collections  of  nuclei  and  small  rounded  cells 
met  with  in  large  quantities  in  those  localities  in  which  these  disintegrating  fibres  were  seen. 
These  processes  were  followed  out  in  the  muscles  surrounding,  and  in  contact  with,  the  ex- 
terior of  the  cancerous  tumor.  Now,  by  the  extension  of  these  destructive  changes,  more 
and  more  of  the  muscular  substance  had  necessarily  become  involved  ;  the  increase  in  size 
of  the  tumor  and   the  enlargement  of  its   boundaries,  being  evidently  primarily  due  to  the 


690  GENERAL  PATHOLOGY  OF  CANCER. 

So  far,  then,  as  the  gradual  change  accomplished  in  a  succession  of 
structures,  or  the  introduction  of  cancer-materials  into  the  elemental 
structures  of  excretory  organs,  can  be  called  a  transformation,  the  term 
is  not  chargeable  with  the  absurdity  which  some  impute  to  it.  And  the 
belief  of  the  possible  transference  of  cancer-material  into  some  gland- 
structure  is  worth  holding,  for  it  encourages  one  of  the  few  hopes  of 
curing  cancer  that  at  present  seem  reasonable, — the  hope,  namely,  that 
means  may  be  found  by  which  the  morbid  substance,  transformed  or 
combined,  may  be  constantly  eliminated  from  the  blood  through  the 
transient  structures  of  some  gland. 

But  these  things  are  only  possible :  the  unhappy  rule  is,  that  the 
natural  consequence  of  the  cancerous  condition  of  the  blood  is,  sooner 
or  later,  the  formation  of  a  cancer  with  specific  structures  and  mode  of 
life.  Concerning  these,  it  may  suffice  if  I  collect  and  comment  upon 
the  principal  facts  detailed  in  the  foregoing  Lectures. 

In  general  construction,  cancers  may  be  either  infiltrations  or  sepa- 
rate masses :  i.  g.,  their  elementary  structures  may  be  either  com- 
mingled, and  form  one  mass,  with  those  of  a  certain  portion  of  a  natural 
part,  or  they  may  be  collected  unmixed  in  a  mass  around  which  the 
natural  tissues  are  extended.  In  any  case,  the  mass  they  form  is  a 
growing  part ;  and  herein  is  the  ground  for  classing  them  with  tumors, 
and  for  separating  them  from  those  results  of  disease,  such  as  inflam- 
matory products  and  tubercle,  which  may  be  increased,  but  probably 
not  by  their  own  power  of  growth.  (See  p.  338,  &c.) 

In  both  their  likeness  and  their  unlikeness  to  other  tumors,  cancers 
exemplify  what  is  common  among  specific  diseases,  namely,  that  they 
take  certain  general  characters  of  common  diseases,  and,  as  it  were, 
stamp  them  with  some  specific  mark.  Syphilitic  eruptions  are  known 
by  some  specific  character,  added  to  those  which  are  common  to  other 
eruptions  of  the  same  group  :  each  specific  form  of  ulcer  has  its  own, 
together  with  common,  characters ;  so,  cancers  have  many  characters 
in  common  with  other  tumors,  but  specific  cancers  are  superadded.  (See 
p.  323.) 

When,  as  in  infiltrations,  the  cancer-structures  are  mingled  with  those 
of  a  natural  part,  the  most  frequent  event  is,  that  the  growth  of  the 
cancer  preponderates,  and  at  length  excludes  that  of  the  natural  struc- 

multiplicatiuii  of  the  nuclei,  which,  through  resuhing  disintegration  of  the  fibres,  were  con- 
tinually being  added  to  the  circumference  of  the  cancerous  tumor,  and  there  assumed  the 
appearance  and  characters  of  true  cancerous  elements. 

Thus,  within  the  muscular  fibre  itself,  and  from  its  pre-existing  nuclear  elements,  the 
descent  of  the  proper  cancer-cells  and  nuclei  could  be  distinctly  traced  ;  and  this  too  in  a 
texture  which,  from  the  very  nature  of  its  structure,  precludes  all  possibility  of  an  exuda- 
tion or  blastema  being  poured  out  into  it.  (A  description  by  Mr.  Syme  of  this  case  of  ex- 
cision of  the  scapula  may  be  found  in  the  April  number  of  the  Edinburgh  Med.  Jal.  for 
1863,  p.  951  ;  and  at  p.  873  of  the  same  number,  the  editor  has  entered  more  at  length  into 
the  discussion  of  the  question  of  the  mode  of  origin,  not  only  of  the  corpuscles  of  cancer,  but 
of  those  of  tubercle  and  pus.) 


GENERAL    CONSTRUCTION    OF    CANCER.  691 

tures;  so  that,  finally,  the  latter  disappear,  and  a  substitution  (to  use 
M.  Lebert's  term)  of  cancer  in  the  place  of  the  natural  tissues,  is 
effected.  But  the  reverse  of  this  sometimes  happens  ;  instead  of  atro- 
phy, hypertrophy  ensues  in  the  natural  structures  of  the  affected  part ; 
and  within  the  same  area  both  normal  and  abnormal  structures  grow 
excessively.  Thus  it  is  with  the  growths  of  bone  that  form  skeletons  of 
the  medullary  cancers,  and  with  those  of  connective  tissue  that  extend 
into  the  exuberant  epithelial  cancers. 

The  developed  cancer-structures,  if  we  except  the  few  cases  in  which 
they  are  fibrous  or  osseous  (pp.  540,  649),  may  be  generally  described 
as  formed  of  nucleated  cells,  or  of  such  corpuscles  as  are  rudimental 
of,  or'  degenerate  from,  the  nucleated  cell.  Herein,  and  in  the  fact 
that  the  corpuscles  are  neither  imbedded  in  formed  intercellular  sub- 
stance, nor  orderly  arranged,  lies  one  of  the  characters  by  which  cancers 
are  distinguished  from  other  tumors,  and  from  all  natural  parts.  Their 
chief  heterology,  in  respect  of  construction,  is  in  this  disorderly  crowd- 
ing of  their  elements  ;  and  I  believe  it  is  constant,  unless  when  they 
imitate  the  plan  of  some  adjacent  natural  gland-structure  (pp.  569,  578). 

We  observe,  in  the  large  majority  of  cancers,  two  primary  or  founda- 
tion-forms of  cells,  of  which  the  respective  types  may  be  found  in 
gland-cells,  and  in  epithelial  or  epidermal  cells.  Of  the  former,  w^e 
have  examples  in  the  ordinary  cells  of  scirrhous  and  medullary  cancers 
(pp.  526,  570) ;  of  the  latter,  in  the  ordinary  epithelial  cancer-cells 
(p.  610) ;  and  it  is,  perhaps,  very  significant  of  the  meaning  of  cancer, 
that  the  forms  Avhich  its  structures  are  most  prone  to  assume  are  after 
the  pattern  of  those  belonging  to  the  natural  structures  whose  office  is 
to  separate  whatever  is  refuse  or  abnormal  from  the  blood. 

I  say,  the  cancer-cells  are  formed  on  the  types  of  excretory  gland- 
cells  and  epidermal  cells ;  yet  without  deviating  from  the  general  type, 
they  have  special  characters  by  which  it  is  seldom  difficult  to  distin- 
guish them.  The  question  is  often  asked.  What  are  the  characters  of 
the  true  cancer-cell  ?  or.  Has  the  microscope  discovered  any  structure 
which  is  decisive  of  cancer,  wherever  it  is  found  ?  The  answers  may 
be, — (1.)  Where  cells,  such  as  are  described  at  pp.  526  and  610  are 
found  alone,  or  chiefly,  composing  a  tumor,  we  may  be  certain  that  the 
tumor  is  a  cancer :  we  may,  therefore,  regard  these  as  especially  can- 
cer-cells. (2.)  When  a  tumor  is  composed,  chiefly,  or  alone,  of  cor- 
puscles, such  as  the  nuclei  described  at  p.  569,  or  any  others  which  we 
can  trace  as  rudiments  or  degenerations  of  the  cancer-cells,  the  diag- 
nosis of  cancer  is  not  less  certain :  structures  such  as  these  are  found 
composing  none  but  cancerous  tumors.  But  if  the  question  be  changed 
to, — Are  there  any  cancers  which  are  not  formed  of  structures  such  as 
these  ? — the  answer  must  be  affirmative :  for  there  are  rare  tumors 
which  present  the  whole  clinical  history  of  cancers,  and  wdiich  should 
therefore  be  called  by  the  same  name,  though  they  have  not  these  pecu- 
liar cancer-structures,  or  have  them  in  very  subordinate  quantity.     I 


692  GENERAL    PATHOLOGY    OF    CANCER." 

do  not  refer  here  to  cancers  of  which  all  the  structures  are  imperfect, 
or  degenerate,  or  diseased ;  but  to  such  as  the  fibrous  cancers  (p.  540), 
the  osteoid  (p.  646),  and  certain  varieties  of  the  medullary  (pp.  570  to 
572),*  These  all  deviate  from  the  assumed  specific  cancer-structures; 
and  two  of  these,  the  fibrous  and  osteoid,  approximate  to  the  characters 
of  natural  tissues. 

Together  with  the  disorderly  construction,  and  the  peculiar  cell-forms, 
we  may  often  observe,  as  characteristics  of  cancers,  the  multiformity  of 
the  structures  composing  their  mass.  It  is  not  equalled,  I  think,  by 
any  tumors,  unless  they  be  the  cartilaginous  or  the  mixed  glandular 
and  cartilaginous  (pp.  437,  454).  The  variety  of  forms  appears  due,  in 
part,  to  the  mingling  of  the  perfect  structures  with  such  as  are  in  va- 
rious stages  of  development  and  degeneration ;  and,  in  part,  to  what 
seems  like  a  disorderly  overgrowth  and  endogenous  increase  in  cells  and 
their  contents.  All  these  forms  have  been  already  described;  but  they 
may  be  thus  enumerated  and  arranged :  (1.)  The  chief  of  those  to  be 
referred  to  incomplete  development  are  the  free  nuclei,  and  abundant 
undeveloped  liquid  or  cancer-juice  (pp.  527,  568,  610).  (2.)  The  chief 
forms  due  to  the  degeneration  are  the  transitions  from  cancer-cells  or 
nuclei  to  granule  masses  (pp.  528,  610) ;  the  withering  corpuscles  with 
fatty  degeneration  found  in  the  material  like  tubercle  in  cancers  (527, 
e.  s.) ;  the  calcareous  deposits  (p.  589) ;  the  abundant  granular  matter; 
and  the  occasionally  mingling  melanoid  cells  (p.  640).  (3.)  Overgrown 
or  abnormally  developed  corpuscles  are  seen  in  the  various  extensions 
of  cell-walls  into  angles  and  processes  (pp.  526,  571,  611)  ;  and  in  the 
enlargement  of  free  nuclei  and  their  assumption  of  the  characters  of 
nucleated  cells  (pp.  527,  569,  611).  (4.)  The  endogenous  increase  in 
cells  is  exemplified  in  all  that  is  described  of  the  brood-cells  and  lami- 
nated corpuscles  of  the  epithelial  and  colloid  cancers  (pp.  613,  66 1). 

It  would  be  too  tedious  even  to  enumerate  more  forms  than  these  of 
the  component  cancer-structures,  and  I  need  not  again  describe  them. 
It  is  not  their  multiformity,  so  much  as  the  existence  of  many  of  them 
in  a  single  mass,  that  is  generally  characteristic  of  cancer. 

Various  as  are  these  corpuscles  of  cancers,  it  is  yet  to  be  observed 
that  there  is  none  so  entirely  different  from  those  of  normal  structures, 
that  we  cannot  point  out  among  them  its  type  or  parallel.  No  obser- 
vation since  Miiller's  time  has  invalidated  his  demonstration  of  this 
principle.  The  experienced  microscopist  will,  indeed,  very  rarely  fail 
in  the  diagnosis  of  a  cancer  by  its  minute  structures ;  but  he  only  dis- 
criminates them  as  specific  modifications  of  the  nucleus,  nucleated  cell, 

*  Some  pathologists  would  exclude  from  the  name  of  cancer  all  these  tumors,  and  all 
which  are  not  composed  of  the  "  specific"  cancer-structures ;  but  I  feel  sure  that  we  shall 
do  right  if  (when  a  choice  must  be  made)  we  choose  modes  of  life,  rather  Than  structures, 
for  determining  the  affinities  of  morbid  products,  and  for  arranging  them  under  generic 
names.  As  of  all  tumors,  so,  especially  of  cancers,  the  true  nature  is  to  be  apprehended 
only  by  studying  them  as  living  things.     (Compare  pp.  339,  509,  665.) 


CANCER-STRUCTURES,     CANCER-CELLS,    ETC.  693 

endogenous  cells,  and  other  forms,  of  Avhich  the  types  are  in  natural 
parts ;  he  finds  among  them  no  new  type-forms.* 

In  like  manner,  the  elemental  cancer-structures  show  no  method  of 
growth  or  development  which  is  without  parallel  in  natural  structures ; 
they  are  formed  and  increased  according  to  the  same  general  laws  as 
are  observed  in  the  normal  rudimental  structures ;  their  peculiarities, 
in  this  regard,  are  chiefly  in  the  seeming  disorder  that  often  prevails 
among  them, — in  the  absence  of  an  apparent  singleness  of  design. 

The  abundance  of  cell-structures  in  cancers  has  suggested  that  they 
are  lowly  organized,  and  many  consequences  have  been  hence  deduced. 
The  terms  "high"  and  "low,"  in  relation  to  structures,  are  derived 
from  very  arbitrary  estimates,  and  are  too  fallacious  for  any  important 
deduction  in  pathology  ;  still,  it  may  be  observed,  that  among  morbid 
products,  cancers  should  stand  high  rather  than  low  ;  for  their  ele- 
mental forms  are  on  a  level  with  those  of  natural  excretory  organs,  and 
more  developed  than  any  but  the  best  inflammatory  lymph.  If  there 
were  any  correspondence,  such  as  has  been  assumed,  between  lowness 
of  organization  and  malignancy,  the  ordinary  croupous  or  corpuscular 
lymph  should  be  a  much  worse  material  than  cancer ;  but  malignant 
properties,  like  malignant  spirits,  are  not  confined  to  the  vilest  forms. 

The  proper  structures  of  cancers  are  supported  and  held  together  by 
fibrous,  membranous,  or  other  connective  tissue,  forming  their  "stroma." 
This  stroma,  as  I  have  elsewhere  described,  is  formed,  in  the  case  of 
cancerous  infiltrations,  by  the  natural  fibrous  or  other  tissues  of  the  in- 
filtrated part,  which,  in  difi"erent  cases,  are  either  gradually  reduced  in 
quantity  or  increased.  In  these  cases  the  stroma  is  no  proper  cancer- 
structure,  and  varies  with  the  nature  of  the  afi"ected  part  (pp.  531,  566, 
604).  But  in  distinct,  isolable,  cancerous  tumors,  a  stroma  is  formed 
appropriate  to  the  cancer,  and,  in  many  cases,  with  a  definite  mode  of 
growth, — the  dendritic  mode  (pp.  575,  655).  Generally,  however,  it  is 
only  in  its  plan  or  construction  that  the  stroma  is  peculiar  ;  its  tissues 
are  simply  membranous,  or  nucleated,  or  filamentous,  or  it  may  be  os- 
seous: they  are  not  cancerous.f  We  see,  therefore,  in  cancers  thus 
formed,  as  well  as  in  the  cancerous  infiltrations  with  overgrowth  of  the 

*  This  is  now  sufficiently  evident  for  all  the  simple  cells  and  nuclei  of  cancer;  and  the 
more  complex  endogenous  cells  and  developing  nuclei  find  their  parallels  especially  in  car- 
tilage, the  preparatory  structure  of  medulla,  and  the  thyroid  and  similar  glands.  (See, 
especially,  Rokitansky  "  Die  Kropf,"  and  "  Ueber  die  Cyste ;"  and  Virchow,  in  his  Archiv, 

B.  iii.) 

f  Exceptions  to  this  statement  must  be  made  for  certain  fibrous  and  osteoid  cancers,  m 
whicli  the  fibrous  and  osseous  tissue,  if  regarded  as  a  stroma  for  the  mingled  cancer-cells, 
must  be  admitted  as  a  proper  cancer-structure;  and  for  some  cases  of  medullary  cancer,  in 
which  a  kind  of  stroma  is  described  as  formed  of 'series  of  elongated  cancer-cells. 

It  must  be  observed,  also,  that  the  line  between  infiltrations  and  isolable  tumors  is  here, 
as  elsewhere,  somewhat  artificially  drawn.  It  is  not  to  be  denied  that  the  latter  may  in- 
volve small  portions  of  natural  tissues,  which  may  remain  intersecting  or  partitioning  their 
masses,  and  supplying  a  framework  upon  which  their  peculiar  stroma  may  be  constructed. 


694  GENERAL  PATHOLOGY  OF  CANCER, 

natural  structures,  the  coincident  growth  of  morbid  and  of  normal  tis- 
sues within  the  same  area,  and  out  of  the  same  mixed  materials. 

With  the  stroma  of  cancers  are  their  bloodvessels,  among  which  we 
must  again  distinguish,  as  in  the  preceding  paragraph,  that  some  are 
the  vessels  of  the  affected  part  now  involved  in  the  cancerous  infiltra- 
tion, others  are  new-formed.  Concerning  the  changes  which  the  first- 
named  may  undergo  in  the  growth  of  the  cancer,  we  have,  I  believe,  at 
present,  no  knowledge.  They  are  not,  as  in  tuberculous  infiltrations, 
gradually  destroyed  or  removed ;  rather  they  seem  to  be  increased ;  so 
that  an  injected  scirrhous  cancer  of  the  breast  (for  example)  often  ap- 
pears more  vascular  than  the  adjacent  substance  of  the  mammary  gland, 
though,  in  the  first  instance,  it  had  only  the  bloodvessels  of  the  part  of 
the  gland  which  it  occupies.  No  direct  observations,  however,  have 
shown  the  method  of  this  increase. 

The  new-formed  bloodvessels  of  the  isolable  cancers  and  the  cancer- 
ous outgrowths  extend  from  those  of  the  adjacent  parts.  It  is  by  some 
thought  that  they  are  formed  as  an  isolated  system  of  tubes  in  the  can- 
cer: I  know  no  satisfactory  evidence  of  this  ;  and  the  associated  theory 
of  blood  being  formed  in  the  substance  of  a  cancer,  and  out  of  cancer- 
materials,  seems  to  me  wholly  untenable.  The  method  in  which  the 
new  vessels  extend  into  cancers  has  not  yet  been  traced,  but  is  proba- 
bly not  different  from  that  observed  in  other  new-formations  (pp.  159, 
255).  Neither  has  anything  specific  in  their  structure  or  method  of 
arrangement  been  yet  observed.  The  descriptions  already  given  of 
them  (pp.  565  and  656)  will  show  that  the  bloodvessels  of  cancers  do 
not  differ  from  those  of  other  abnormal  growths,  except  in  that  gene- 
rally, their  calibre  is  more  than  proportionate  to  the  thickness  or  com- 
plexity of  structure  of  their  walls.  Hence  the  term  "  colossal  capilla- 
ries ;"  and  hence,  when  the  bloodvessels  are  abundant,  the  likeness  to 
the  simple  vascular  erectile  tumors  :  but  in  neither  of  these  respects  are 
the  vessels  of  cancer  without  parallel  in  those  of  natural  parts  ;  those 
of  the  placenta  and  of  the  cavernous  erectile  tissue  might  be  their  types. 

Such  are  the  component  structures  of  cancers.  We  might  hope  that 
chemistry,  carrying  its  analysis  far  beyond  the  reach  of  sight,  would 
find  in  them  something  as  different  from  natural  compositions,  as  their 
mode  of  life  is  from  that  of  any  natural  member  of  the  body.  But  it 
has  failed  to  do  this  ;  and  the  numerous  analyses  made  since  those  of 
Miiller  have  not  materially  added  to  his  results.*  In  a  general  com- 
parison, the  cancers  are  distinguished  by  the  predominance  or  exclu- 
sive existence  of  albuminous  compounds,  while  in  the  non-cancerous 
tumors  gelatinous  compounds  (or  in  the  adipose  tumors,  the  fatty)  are 
the  chief  constituents.  But  there  are  large  exceptions  on  both  sides. 
The  fibrous  and  osteoid  cancers  yield  abundant  gelatine ;  the  albumi- 

*  The  best  of  these  analyses  may  be  found  in  Lebert's  Trait6  Pratique,  p.  44,  e.  s. 


LIFE    OF    CANCERS:    GROWTH.  695 

nous  sarcomata  of  Miiller  (including,  probably,  many  of  the  least  de- 
veloped proliferous  cystic  tumors  and  the  recurring  fibroid  tumors)  are 
as  albuminous  as  the  typical  cancers.  It  is  probable,  moreover,  that 
the  broad  general  difiFerence  between  albuminous  and  gelatinous  growths 
is  not  directly  related  to  their  respective  properties,  as  malignant  and 
innocent,  but  to  their  retaining  or  passing  beyond  the  cell- form. 

The  want  of  a  more  definite  result  from  chemical  analysis  is  not  to 
be  ascribed  to  the  absence  of  difference  between  cancerous  and  normal 
materials, — we  may  be  nearly  sure  that  they  are  chemically  essentially 
distinct, — but,  rather,  to  the  fact,  that  an  exact  analysis  of  cancer-struc- 
tures is  nearly  impossible.  That  which  would  be  given  to  a  chemist 
for  examination  is  not  a  pure  cancer-material,  but  a  mixture  of  it  with 
the  materials  of  blood,  bloodvessels,  connective  tissue,  and,  in  many 
cases,  of  the  natural  or  degenerate  structures  of  the  part  in  which  the 
cancer  has  been  growing.  Add  to  this,  that,  in  every  sample,  the  can- 
cer-structures themselves  are,  probably,  in  all  stages  of  development 
and  degeneration,  and  the  search  for  the  essential  chemical  properties 
of  cancer  will  surely  seem  as  difiicult  as  it  would  be  to  find  those  of 
muscle,  or  of  bone,  in  the  analysis  of  the  whole  of  a  foetal,  or  of  a 
paralytic  limb.* 

In  studying  the  life  of  a  cancerous  growth,  we  have  always  to  con- 
sider it  as  adding  to  the  conditions  of  disease  which  already  existed, 
and  which  usually  still  continue  ;  it  is  a  new  factor  in  an  already  com- 
plex morbid  process.  The  formation  of  cancerous  material  in  the  blood 
does  not  cease  because  some  is  incorporated  in  a  growth  ;  the  transfor- 
mations of  parts,  making  them  apt  for  the  allocation  of  cancer,  do  not 
cease  because  one  part  is  occupied.  In  all  the  history  of  cancers, 
therefore,  we  have  to  study  the  continuation  of  those  processes  which  I 
have  described  in  the  last  Lecture,  as  preceding  the  growth  of  the  can- 
cer, and  which  now  (with  rare  exceptions)  are  concurrent  with  it,  and 
increase  with  it. 

Before  the  formation  of  a  cancerous  growth,  we  trace  two  distinct, 
though  usually  concurrent,  processes ;  namely,  that  which  leads  to  the 
cancerous  condition  of  the  blood,  and  that  which  makes  certain  parts 
fit  to  be  seats  of  cancerous  growths.  When  once  a  growth  is  formed, 
it  introduces  a  third  element  of  disease,  without  necessarily  removing 
or  diminishing  either  of  those  that  preceded  it.  As  a  living  part,  the 
cancer,  like  any  other  tumor,  has  the  power  of  self-maintenance  and  of 
growth,  which  power,  though  favored  by  the  continued  or  increasing 
cancerous  condition  of  the  blood,  is,  probably,  not  dependent  thereon. 
Also,  in  the  results  of  its  nutrition,  the  cancer  reacts  upon  the  blood, 
and  through  it  influences  the  whole  economy ;  and  these  influences  are 

*  The  case  of  the  colloid  ntiaterial  may  seem  not  open  to  this  objection  ;  but  the  colloid  is, 
probably,  not  a  true  cancer-substance,  but  the  product  of  disease  in  cancer. 


696  GENERAL  PATHOLOGY  OF  CANCER. 

added  to  the  cancerous  diathesis  or  cachexia  which  is  usually,  at  the 
same  time  and  of  itself,  increasing. 

The  manifestations  of  life  in  a  cancer  may  be  divided  (but  it  is  too 
artificial  a  division  to  be  followed  far)  into  those  which  are  progressive 
and  those  which  are  retrogressive.  The  latter  are  traced  in  the  various 
degenerations  and  diseases  of  its  structures  ;  the  former  in  its  growth, 
extension,  and  multiplication. 

The  chief  characteristics  of  the  growth  of  cancers  are  seen,  in  those 
that  are  infiltrated,  in  their  invasion  of  all  tissues,  as  if  indifi"erently. 
Thus  the  scirrhous  cancer  of  the  breast,  though  limited  for  a  time  to 
the  mammary  gland,  at  length  extends  beyond  it,  and  gradually  occu- 
pies every  surrounding  part  alike :  thus  the  epithelial  cancer  extends 
from  the  integument  of  the  lip  to  its  muscles,  glands,  and  all  deeper 
tissues,  and  thence  to  the  gum  and  jaw  ;  and  thus  the  medullary  cancer 
grows  into  and  through  the  walls  of  bloodvessels  and  other  canals,  and 
extends,  among  their  contents,  along  their  cavities.  Such  reckless 
growth  (if  it  maybe  so  called)  is  scarcely  known  except  in  cancers. 
They  supply,  also,  the  instances  of  most  rapid  increase ;  but  although 
they  do  this  frequently  enough  to  make  rapid  growth  one  of  the  diag- 
nostic signs  of  cancers,  yet  the  cases  are  far  from  rare  in  which  the 
growth  is  very  slow.  Few  diseases  are  more  variable  than  cancers  are 
in  this  respect.     (Compare  pp.  531,  585,  631.) 

It  has  been  assumed  that  the  appearances  of  endogenous  increase  in 
certain  cancer-cells  are  indicative  of  a  peculiar  inherent  capacity  of 
growth.  But  this  is  far  from  certain,  and  is  made  improbable  by  the . 
fact  that  the  endogenous  productions  are  most  abundant  in  epithelial 
cancers,  whose  average  rate  of  increase  is  least ;  and  that  those  medul- 
lary cancers  which  have  only  free  nuclei,  or  imperfect  nucleated  cells, 
are  among  those  of  most  rapid  growth.  The  rule  is  more  nearly  true, 
which  these  instances  exemplify,  that  the  rapidity  of  growth  among 
cancers  is  inversely  proportionate  to  the  development  of  their  elemental 
textures.  But  this  finds  exceptions  in  the  very  quickly  increasing  and 
multiplying  fibrous  and  osteoid  cancers. 

Two  things  administer  to  the  growth  of  a  cancer ;  namely,  (1)  the 
continued  formation  of  the  specific  material  in  the  blood  ;  and  (2)  the 
inherent  power  in  the  cancer,  as  a  living  part,  to  assimilate  to  itself  the 
common  or  indifferent  materials  of  the  blood.  The  first  of  these  main- 
tains and  augments,  as  it  originated,  the  growth ;  the  second  efi'ects  an 
independent  increase,  like  that  of  a  non-cancerous  tumor. 

In  ordinary  cases,  both  these  conditions  are  engaged  in  the  growth 
of  cancer  ;  but,  if  the  first  fail,  the  second  may  sufiice.  The  cancerous 
diathesis  may  cease,  or  be  exhausted  for  a  time,  or  sometimes  even  per- 
manently ;  cancer  material,  we  may  suppose,  is  no  longer  formed  in  the 
blood ;  yet  the  cancer  may  subsist  and  increase  by  its  own  power.  It 
does  so  like  any  other  tumor  ;  especially  like  those  which  I  mentioned 


EXTENSION    IN    LYMPHATICS.  697 

(p.  348)  as  beginning  during  or  after  some  general  disease,  but  continu- 
ing to  grow  when  that  disease  had  ceased. 

Now,  in  this  state,  the  cancer  is  essentially  a  local  disease,  living  upon 
the  materials  of  blood  restored  to  health,  though  capable,  probably,  of 
infecting  that  blood,  and  inducing  secondary  phenomena  of  extension 
and  multiplication.  It  illustrates,  in  this  state,  a  principle  which  we 
are  too  apt  to  forget :  namely,  that  diseases  of  constitutional  origin 
may  become  wholly  local.  The  origin  of  local  diseases  in  constitutional 
conditions  has  been  well  studied,  and  the  necessity  of  constitutional 
treatment,  in  chronic  as  well  as  in  acute  diseases,  has  been  rightly  re- 
ferred to  the  local  affections  being  maintained  by  the  continued  morbid 
condition  of  the  blood  ;  but  it  has  been  less  considered  that,  after  the 
constitutional  disease  has  ceased,  the  local  one  may,  of  itself,  continue, 
and  need  local  treatment.  Such  cases  are  very  frequent.  One  often 
sees  syphilitic  ulcers,  which,  doubtless,  had  a  constitutional  origin,  and 
were  maintained  by  specific  material  in  the  blood,  and  would  have 
needed  specific  treatment  of  the  blood  for  their  cure ;  but  now,  while 
retaining  their  specific  forms,  they  are  curable  by  local  treatment  alone. 
Just  so  it  may  be,  though  very  rarely,  with  cancers.  While  the  cancer- 
ous diathesis  is  suspended,  they  may  subsist  by  their  own  powers  of 
assimilation ;  and  I  believe  the  few  credible  cases  of  recovery  after 
operation  are  to  be  referred  to  the  chances  which  have  led  to  the 
occasional  removal  of  such  as  were  thus  localized. 

The  extension  of  cancer  (so  far  as  it  may  be  distinguished  from  their 
growth)  is  that  which  takes  place  through  lymphatic  vessels  to  their 
glands.  The  number  of  cases  in  which  lymphatics,  filled  with  cancer, 
have  been  traced  from  the  primary  growth  to  the  nearest  glands,  is 
sufficient  to  make  it  probable  that  the  disease  often  thus  extends  con- 
tinuously from  the  one  to  the  other ;  and  that  it  is  thus,  as  Mr.  Simon 
expresses  it,  transferred  by  "  continuity  of  blastema."  But,  even  when 
such  tracts  of  cancer  cannot  be  traced  from  the  primary  disease  to  that 
in  the  lymphatic  glands,  I  think  Mr.  Simon's  suggestion  is  very  proba- 
bly true, — that  the  disease  is  one  of  the  lymph,  not  of  the  parenchyma 
or  vessels  of  the  glands.  We  do  not,  indeed,  yet  know  exactly  the  de- 
rivation of  the  lymph,  nor  what  is  its  relation  to  the  materials  of  the 
part  from  which  it  comes ;  but  what  we  do  know  of  it  is  consistent  with 
the  belief,  that  lymph,  from  the  seat  of  specific  disease,  is  likely  to  con- 
tain such  of  the  materials  of  the  disease  as  may  either  be  carried  to 
the  blood,  or  may  be  organized  in  the  lymph  after  the  same  plan  as  in 
their  primary  seat. 

The  characters  of  the  secondary  cancers  thus  formed  in  lymphatic 
glands,  are  already  described  (pp.  533,  580,  616,  &c.);  and  these  gene- 
ral principles  may  be  gathered  concerning  them. 

(1.)  The  disease  in  the  lymphatic  glands  usually  repeats  exactly  that 
in  the  primary  seat ;   the  apparent  differences  between   them  depend 

45 


698  GENERAL  PATHOLOGY  OF  CANCER. 

only  on  the  structures  among  which  the  cancerous  elements  are  placed. 
But  this  rule  is  not  without  exceptions  (p.  534,  &c.,  as  cited  above). 

(2.)  The  cancer  in  the  glands  seldom  appears  before  that  in  the  pri- 
mary seat  has  made  considerable  progress.  At  a  general  rough  esti- 
mate, it  appears  about  midway  in  the  course  of  the  disease  towards 
death.  The  delay  is,  perhaps,  not  to  be  explained,  seeing  that  lymph 
is  carried  from  the  primary  disease  as  well  in  its  earlier  as  in  its  later 
stages. 

(3.)  While  the  disease  in  the  glands  makes  progress,  the  primary  dis- 
ease usually  keeps  the  lead  which  its  earlier  origin  gives  it.  Occasion- 
ally, however,  that  in  the  glands  so  far  surpasses  it  that  we  are  in  dan- 
ger of  overlooking  the  primary  disease  (p.  534,  &c.).  I  do  not  know  how 
the  fact  can  be  explained ;  but  it  has  its  parallel  in  the  occurrence  of 
primary  cancer  in  the  glands  that  are  usually  secondarily  diseased,  and 
in  the  recurrence  of  cancers  after  operations  in  the  glands,  rather  than 
in  or  near  its  primary  seat. 

(4.)  The  lymphatic  glands  us'ually  become  cancerous  in  direct  succes- 
sion from  the  primary  disease  to  the  thoracic  duct.  The  extension  is, 
generally,  made  slowly  ;  in  scirrhous  and  epithelial  cancers,  the  disease 
often  remains  long  limited  to  the  glands  nearest  to  its  primary  seat ;  in 
nearly  all  cases,  also,  it  is  prone  to  increase  in  these  proximate  glands 
much  more  than  in  those  more  distant.  Rarely,  the  secondary  cancer 
appears  in  distant  rather  than  in  proximate  glands  ;  but  in  these  cases, 
it  illustrates  the  multiplication,  not  the  extension,  of  disease. 

The  multiplication  or  discontinuous  increase  of  cancers  may  take 
place  in  the  following  ways  : 

(1)  The  cancer-growth  may  multiply  itself,  from  its  primary  seat,  to 
a  part  not  directly  continuous,  but  in  contact,  therewith.  Thus  Dr. 
Hodgkin  and  Dr.  Budd  relate  cases  of  cancer  in  abdominal  and  pelvic 
viscera,  with  corresponding  formations  on  the  portion  of  parietal  peri- 
toneum or  other  parts  in  contact  with  them  ;  and  thus  there  may  be 
correspondence  and  contact  of  cancers  on  the  two  layers  of  pleura,  or 
on  the  glans  and  prepuce. 

(2)  The  multiplication  may  take  place  on  a  surface  not  in  contact, 
but  continuous,  with  the  primary  seat ;  as  in  cases  by  Mr.  Simon  (1.  c), 
in  which  cancerous  growths  were  found  scattered  along  the  tract  of  mu- 
cous membrane  leading  from  primary  cancers  in  the  kidney  and  lung. 

In  both  these  cases,  the  multiplication  of  the  cancers  seems  to  be  the 
result  of  simple  transference  of  the  materials  from  the  primary  to  the 
secondary  seat  of  growth :  it  is  eifected  by  a  kind  of  inoculation.  The 
materials  of  a  cancer  pass  from  its  mass,  and  develop  themselves,  and 
grow,  where  they  rest. 

(3)  Cancers  are  multiplied  in  parts  neither  directly  continuous,  nor 
in  contact,  with  the  primary  seat.  In  some  instances  the  parts  are  near, 
in  others  remote  from,  the  primary  disease. 

When  cancers  are  thus  multiplied  near  their  primary  seat  by  "  irra- 


MULTIPLICATION    OF    CANCERS.  699 

diation,"  we  find  them,  as  it  were,  springing  up  in  an  area  which  gradu- 
ally widens,  and  of  which  the  primary  cancer  is  the  centre.  Thus  it 
is  with  the  tubercles  in  the  skin  and  muscles  near  a  scirrhous  breast 
(p.  535);  and  with  the  secondary  medullary,  osteoid,  and  melanoid 
growths  scattered  around  the  main  disease,  but  separated  from  it  by 
intervals  of  healthy  tissue  (pp.  644,  651). 

I  do  not  know  that  we  can  explain  this  mode  of  increase  of  cancers 
otherwise  than  by  reference  to  the  seeming  tendency  of  specific  diseases 
to  be  allocated,  not  only  in  certain  tissues  or  organs,  but  in  certain 
places  or  regions  (p.  577).  Certainly,  peculiarities  of  tissue  have  little 
to  do  with  this  grouping  of  the  cancers  around  the  primary  formation ; 
for  they  may  be  found,  promiscuously,  in  all  the  surrounding  tissues 
within  a  certain  area.  Neither  does  the  course  of  lymphatic  or  other 
vessels  seem  to  determine  their  places. 

In  the  increase  of  cancers  by  multiplications  distant  from  the  pri- 
mary growth,  there  is  scarcely  an  organ  that  may  not  be  afi'ected.  We 
see  this  most  easily  in  the  cases  of  melanoid  cancers ;  yet  their  multi- 
plicity is,  probably,  not  greater  than  that  of  other  medullary  cancers 
(see  p.  439).  The  cancers  that  thus  least  frequently  multiply  are  the 
epithelial  and  colloid,  and  those,  of  whatever  kind,  in  the  rectum,  uri- 
nary organs,  uterus,  and  brain.  The  organs  in  which  the  secondary  can- 
cers formed  by  multiplication  are  most  frequently  found  are  the  liver  and 
lungs.  After  these  organs,  the  most  frequent  seats  of  such  secondary 
cancers  are,  I  believe,  the  pleura,  bones,  lymphatic  glands,  and  subcu- 
taneous tissue ;  after  these,  no  rule  or  proportion  can  be  stated,  except 
that  many  of  the  organs  in  which  primary  cancers  are  most  frequent 
are  very  rarely  the  seat  of  secondary  cancer ;  e.  g.,  the  breast,  uterus, 
testicle,  and  stomach.* 

At  present,  probably,  none  but  a  very  general  explanation  of  this 
multiplication  of  cancers  can  be  given :  we  can  scarcely  venture  to  guess 
what  determines  the  above-mentioned  peculiarities.  The  general  ex- 
planation may  refer  the  multiplication  to  two  sources,  which  are  in- 
dependent, though  concurrent  and  mutually  influential ;  namely,  the 
increasing  cancerous  diathesis  or  morbid  condition  of  the  blood,  and 
the  conveyance  and  transplantation  of  cancerous  matter  by  the  circu- 
lating blood. 

The  constant  increase  of  the  morbid  condition  of  the  blood  was 
shown,  in  the  last  Lecture,  to  be  a  general  fact  in  the  history  of  can- 
cers. And,  though  it  may  sometimes  be  represented  only  by  the  accele- 
rating growth  of  the  primary  tumor,  yet  we  might  well  expect  that  it 
would  often  produce  a  numerical  increase  of  cancers.  The  common 
indication  of  the  most  intensely  constitutional  cancerous  disease  is  the 
simultaneous  or  rapid  formation  of  numerous  primary  growths  in  differ- 
ent parts.    This  is  sometimes  witnessed  at  the  very  onset  of  the  disease 

*  Lebert  gives  the  best  statistics  on  all  these  points  (p.  81). 


700  GENERAL  PATHOLOGY  OF  CANCER. 

(pp.  580,  585) ;  and  it  is,  probably,  also  exemplified  in  the  later  periods 
of  ordinary  cases.  Certain  cases  scarcely  admit  of  explanation,  on  the 
supposition  that  the  first-formed  cancer  is,  in  any  sense,  the  source  of  all 
that  grow  after  it :  such,  for  example,  as  those  in  which  a  sudden  rapid 
multiplication  of  cancers  takes  place  (p.  586)  and  those  in  which  they 
appear  some  long  time  after  the  removal  of  the  first-formed  growth. 

The  second  method  of  remote  multiplication  of  cancers,  that  of 
conveyance  by  the  blood,  is  sometimes  visibly  demonstrated,  and  may 
almost  always  be  assumed.  I  have  spoken  of  cases  (p.  673)  in  which 
cancers  so  grow  into  veins,  that  we  cannot  doubt  fragments  may  be 
washed  from  them  by  the  blood,  and  may  grow  wherever  they  come  to 
rest ;  and  I  related  one  instance  of  osteoid  cancer  in  which  this  almost 
certainly  occurred  (p.  652).  But,  even  when  no  such  intra-vascular 
growths  appear,  similar  events  may  occur.  In  a  case  of  primary  can- 
cer of  the  liver,  in  which  the  growths  were  all  tinted  with  bright  yellow 
by  the  bile,  I  found  numerous  small  cancerous  masses  of  the  same  color 
infiltrated  in  the  lungs ;  and  the  small  branches  of  the  pulmonary  arte- 
ries leading  to  these  were  filled  with  bright  yellow  substance,  as  if  they 
had  been  minutely  injected  with  chromate  of  lead.  The  accidental  color 
of  the  cancer-materials,  in  this  case,  made  their  transference  from  the 
liver  to  the  lungs  very  evident ;  but  the  same  event  is  often,  though 
less  plainly,  traceable. 

The  transference  of  cancer-materials,  with  the  blood  from  a  cancer 
already  formed,  need  not  be  always  seen  to  be  believed.  Its  frequent 
occurrence  is  made  very  probable  by  the  many  points  of  correspondence 
which  Dr.  Walshe*  has  shown,  between  the  dissemination  of  cancers, 
and  that  of  secondary  abscesses  after  the  entry  of  pus  or  other  degene- 
rate inflammatory  products  into  the  veins.  The  peculiar  liability  of  the 
liver  and  the  lungs  to  be  the  seats  of  both  these  secondary  diseases, 
and  the  evidence  that  they  are  the  organs  in  which  foreign  matters, 
introduced  into  the  circulation,  are  most  commonly  arrested,  may  nearly 
prove  that  they  are,  in  all  these  cases  alike,  affected  by  materials  brought 
to  them  in  the  blood. 

We  need  not  assume  that  corpuscles  of  pus  or  cancer,  or  any  kind  of 
germs  already  formed,  must  be  thus  carried  for  the  multiplication  or 
dissemination  of  disease.  A  rudimental  liquid,  an  unformed  cancerous 
blastema,  mingled  with  the  blood,  may  be  as  effectual  as  any  germs ; 
and  must  almost  necessarily  be  assumed,  in  the  explanation  of  cases  in 
which  the  dissemination  takes  place,  not  in  the  lungs  or  liver,  but  in 
organs  beyond  them  in  the  course  of  the  circulation. 

The  materials  conveyed  with  the  blood  from  the  primary  cancer  must 
be  such  as  are  capable  of  development,  in  order  to  the  multiplication  of 
the  disease.  In  the  ordinary  absorptions  occurring  in  the  process  of 
natural  nutrition,  and  probably,  also,  in  those  that  take  place  in  the 

*  Nature  and  Treatment  of  Cancer,  p.  106. 


MULTIPLICATION    OF    CANCERS.  701 

nutrition  of  cancers,  the  venous  blood  carries  away  only  degenerate  or 
refuse  materials,  sucli  as  we  may  assume  would  be  incapable  of  develop- 
ment. I  have  mentioned  cases  (pp.  580,  590),  in  which  masses  of  can- 
cer, probably  thus  degenerate,  were  absorbed,  without  any  appearance 
of  consequent  dissemination  or  other  damage.  We  do  not  know  what 
leads  to  the  removal  of  such  cancerous  matter  as  can  be  developed ;  but 
the  necessity  of  some  change  in  the  ordinary  process  of  absorption  is 
evident,  and  is  the  more  worth  studying  because  there  are  correspond- 
ing similar  differences  in  the  effects  of  the  absorption  of  pus  and  other 
morbid  products. 

Such  are  the  various  means  of  numerical  increase  of  cancers, — by 
local  inoculation  of  parts  continuous,  or  in  contact,  with  the  primary 
disease  ;  by  extension,  through  a  continuity  of  lymph  or  of  blastema, 
to  the  lymphatic  glands ;  by  transportation  of  potent  cancer-materials 
with  the  venous  blood ;  by  the  cancerous  condition  of  the  blood  becom- 
ing, of  itself,  more  intense.  In  certain  cases,  the  increase  may  be  ac- 
complished by  all  these  means  at  once ;  the  secondary  cancers,  also,  as 
soon  as  formed,  become  like  centres,  from  which  a  tertiary  formation 
may  be  derived,  as  they  were  themselves  derived,  from  the  primary  ; 
and  to  all  this  it  may  be  added,  that,  with  lapse  of  time  and  failinor 
general  health,  all  parts  of  the  body  are  constantly  becoming  less 
resistant  of  disease,  and  more  appropriate  for  the  residence  of  morbid 
growths. 

I  have  now  to  trace  a  general  history  of  the  retrogressive  life  of  can- 
cers ;  of  that  which,  as  I  said  (p.  696),  is  signified  in  their  various  de- 
generations and  diseases. 

The  degenerations  of  cancer-structures  are  like  those  of  natural  parts, 
and  of  other  products  of  disease.  Examples  may  be  cited  of  every  form 
corresponding  with  those  enumerated  on  page  84  and  259.  (1)  The 
withering,  or  wasting  and  drying,  of  the  structures  is  exemplified  in 
many  scirrhous  and  epithelial  cancers  (pp.  532,  611);  (2)  the  fatty  de- 
generation is  so  common  that  it  might  be  hard  to  find  a  cancer  in  some  of 
whose  corpuscles  it  does  not  exist.  The  granule-masses  ("the  mulberry- 
cells")  of  cancers  are  hence  derived,  as  they  are  from  many  more  morbid 
products.  Hence,  too,  the  "  saponification"  of  cancers  (p.  588),  while 
to  the  fatty  degeneration,  combined  with  more  or  less  of  withering,  we 
may  ascribe  the  masses  of  substance,  like  tubercle,  so  often  imbedded 
in  medullary  cancers  (p.  564),  and  the  minuter  spots  and  lines  of  soft 
ochre  yellow  substance  traversing  scirrhous  and  medullary  cancers, 
like  a  "reticulum"  (pp.  528,  588).  (3)  A  calcareous  degeneration  is 
observed  in  medullary  cancers,  and  in  osteoid  (pp.  589,  649) ;  and/  pro- 
bably, exists  in  many  instances,  mingled  with  the  fatty  degeneration. 
(4)  Pigmental  degeneration  is  probably  the  essential  character  of  me- 
lanoid  cancers  (p.  643).  (5)  Thickening  of  primary  membrane  is,  per- 
haps, indicated  in  some  of  the  cancer-cells  whose  walls  appear  simply 


702  GENERAL  PATHOLOGY  OF  CANCER. 

laminated  (p.  612,  Fig.  103,  d).  A  liquefactive  degeneration  may 
occur  in  some  of  the  softenings  of  cancers  ;  but,  so  far  as  I  know,  it 
ensues  only  in  connection  with  disease.     (Compare  p.  284.) 

In  the  interpretation  of  degeneracy  in  cancers,  we  must  again  refer 
to  the  two  conditions  of  their  life ;  namely,  the  maintenance  of  the  mor- 
bid condition  of  the  blood,  and  their  inherent  power  of  self-maintenance. 
The  supervention  of  another  diathesis  may  lead  to  the  degeneration  or 
death  of  a  cancer  (pp.  550,  590) ;  but  this  is  extremely  rare.  A  trans- 
formation of  diathesis  may,  I  am  disposed  to  believe,  lead  to  the  de- 
generation of  one  cancer  while  it  promotes  the  growth  of  one  or  more 
others ;  for  there  are  cases  of  apparent  metastasis  of  cancer,  in  which 
the  primary  disease  has  withered,  while  secondary  growths  appear  to 
have  increased.*  But  these  cases,  again,  are  too  rare  to  be  reasoned 
from ;  and  the  usual  course  of  events  indicates  that  degeneration  of  can- 
cer is,  in  the  great  majority  of  cases,  an  essentially  local  thing.  For, 
commonly,  part  of  a  cancer,  or  one  mass  in  a  group,  degenerates,  while 
growth  continues  in  the  rest ;  and  extensive  degeneration  is  often  found, 
in  cases  in  which  the  rapid  progress  of  the  disease  has  testified  to  the 
full  maintenance  of  the  morbid  blood.  Hence  the  unhappy  rarity  of 
the  recovery  from  cancer.  One  that  is  degenerate  or  absorbed  may  be 
as  ineffective  for  harm  as  one  that  has  been  cut  away ;  but  the  consti- 
tutional element  and  progress  of  the  disease  are  as  little  affected  by  the 
natural  as  by  the  surgical  process  of  removal. 

"We  cannot  tell  what  are  the  local  events  that  lead  to  this  degenera- 
tion ;  but  I  suspect  that  the  chief  of  them  is  the  local  obstruction  of 
bloodvessels  by  growths  of  cancer  into  them. 

The  diseases  of  cancers,  like  the  degenerations,  are  essentially  local 
processes ;  they  are  most  apt,  indeed,  to  occur  in  the  enfeebled  general 
health,  but  they  do  not  certainly  indicate  a  decreased  diathesis.  It 
may  suf&ce  to  refer,  for  examples  of  most  of  the  diseases,  to  those  al- 
ready cited  (pp.  547,  590,  &c.) ;  but  two  require  more  consideration  ; 
namely,  softening  and  ulceration. 

Some  have  believed  that  softening  is  almost  a  natural  event  in  can- 
cers, a  change  parallel  with  that  in  tuberculous  deposits,  and  a  neces- 
sary precedent  of  ulceration ;  while  others,  recoiling  from  the  error  of 
this  belief,  have  written  of  the  softening  of  cancers  as  a  rare  and  unim- 
portant accident.  The  truth  is  about  midway  between  these  extremes. 
There  is  no  probability  that  (as  some  have  supposed)  the  hard  scirrhous 
cancers  ever  become  medullary  by  any  process  of  softening ;  a  softened 
cancer  is  very  different  from  a  soft  one.  There  is  no  natural  tendency 
in  cancers  to  become  soft  in  their  later  stages  :  those  of  the  oldest  date 
comrhonly  retain,  if  they  do  not  increase,  their  original  consistence. 
Neither  is  softening  a  necessary  precursor  of  the  ulceration  of  cancers. 
But  any  scirrhous  or  other  cancer  may  be  softened  by  degeneration,  or, 

*  Cases  cited  by  Walshe,  pp.  110,  134. 


DISEASES     OF    CANCERS.  703 

more  effectually  and  extensively,  by  inflammation  of  its  substance.  The 
fatty  degenerations  of  which  I  have  just  been  speaking  are  usually  at- 
tended with  a  softening  ;  but  the  altered  substance  becomes  drier  and 
more  greasy  than  before  ;  it  does  not  appear,  in  any  degree,  liquefied 
(p.  529).  That  which  is  generally  understood,  as  softening  of  cancer  is, 
so  far  as  I  have  seen,  a  more  acute  process,  and  the  result  of  inflam- 
mation of  its  substance.  One  may  see  it  very  Avell  in  the  exposed 
protruding  growths  of  medullary  cancers  (p.  589) ;  or  in  those  parts 
of  them  which  lie  just  beneath  inflamed  portions  of  the  integuments. 
Sometimes,  also,  within  scirrhous  cancers  that  have  rapidly  enlarged, 
with  heat  and  pain,  and  redness  of  the  superjacent  skin,  one  finds  large 
portions  liquid,  or  else  very  soft,  as  it  were  rotten,  shreddy,  and  infil- 
trated with  pale,  yellow,  serous  or  puriform  fluid.  Sometimes  such 
softening  has  distinct  appearance  of  suppuration  in  the  centre  of  the 
cancer  ;  but  these  cases  (which  have  suggested  the  terms  cancerous 
suppuration  or  abscess)  are,  I  think,  most  frequent  in  the  secondary 
epithelial  and  medullary  cancerous  affections  of  lymphatic  glands  (pp. 
591,  617). 

If,  as  I  believe,  these  softenings  of  cancer  are  the  results  of  inflam- 
mation, they  correspond  with  the  softenings  produced  by  the  same  dis- 
ease in  natural  parts  (p.  276) ;  they  are  the  results  of  such  defective 
nutrition  as  always  ensues  in  the  proper  textures  of  an  inflamed  part ; 
and  when  pus  is  diffused  in  the  softened  cancer-substance,  the  process 
may  be  compared  with  ordinary  purulent  infiltration,  which  is  always 
attended  with  loss  of  consistence  in  the  affected  part.  With  this  view 
the  microscopic  characters  of  the  softened  cancers  agree. 

Such  softening  as  this,  taking  place  within  a  cancer,  generally  leads 
to  ulceration,  and  to  the  discharge  of  the  liquefied  and  degenerate  mate- 
rials, with  whatever  of  serum,  or  pus,  or  blood  may  have  been  mingled 
with  them.  This  discharge  is  essentially  similar  to  the  opening  of  an 
abscess ;  but  it  is  less  regular,  and  the  ulceration  is  quickly  more  de- 
structive, and  exposes  widely  the  cancerous  walls  of  the  evacuated  cavity. 

I  have  already  described  both  this  and  the  other  forms  of  ulceration 
that  may  ensue  in  cancers  (pp.  547,  586,  608).  They  are  all,  like  the 
degenerations,  essentially  local  processes,  and  not  indicative  of  any  pe- 
culiar advance  or  transformation  of  the  cancerous  diathesis.  Ulceration 
is,  indeed,  a  feature  of  the  later  progress  of  cancer,  and  it  is  most  likely 
to  occur  in  those  whose  health  is  most  enfeebled ;  it  is,  therefore,  often 
coincident  with  an  exceeding  intensity  of  constitutional  disease ;  but  it 
is  not  the  consequence  of  such  intensity.  The  amount  of  constitutional 
disease  is  indicated  by  the  growth,  or  by  the  multiplication,  of  cancers 
rather  than  by  anything  which,  like  ulceration,  implies  imperfect  main- 
tenance of  their  structures  ;  and  so  we  commonly  see  one  part  of  a 
cancer  growing  rapidly,  while  another  is  being  destroyed  by  ulceration, 
or  many  growing  while  one  is  ulcerating.  Now  the  growth  is,  gene- 
rally, the  measure  of  the  force  of  the  constitutional  disease;  the  ulcera- 


704  GENERAL     PATHOLOGY    OF    CANCER. 

tion  is  the  measure  of  the  local  defect  of  nutrition :  and  in  these  in- 
stances we  may  watch,  at  once,  both  the  progressive  and  the  retrogres- 
sive phenomena  of  the  life  of  the  cancer. 

While  dwelling  on  the  constitutional  origin  of  cancerous  growths,  I 
must  not  forget  their  constitutional  effects, — the  changes  in  the  blood 
and  other  parts  which  are  their  consequences. 

I  said  that  a  cancer  adds  a  new  element  of  disease  to  those  that  were 
already  in  progress.  And  this  may  be  said  of  it  in  consideration  both 
of  its  own  life,  and  of  the  influence  which  its  growth  and  changes  have 
upon  the  whole  economy.  If  we  assume  a  constant  process  of  nutrition 
in  cancers,  it  cannot  but  be  that  the  blood  will  be  affected  both  by  what 
they  take  from  it,  and  by  what  it  derives  from  them  in  the  process  of 
nutritive  absorption.  This  latter  source  of  change  of  the  blood  has 
been  too  little  considered, — the  former,  perhaps,  too  much ;  for  the 
quantity  of  good  nutrient  material  abstracted  from  the  blood,  in  the 
growth  of  a  cancer,  is  probably  very  trivial,  whereas  what  returns  to 
the  blood  is  almost  necessarily  a  morbid  substance.  It  may  be  incapable 
of  development  into  cancer,  but,  unless  it  can  be  at  once  eliminated,  it 
must  injuriously  affect  the  blood.  What  change  it  works  we  cannot 
tell ;  nor  can  we  tell  more  of  the  later  changes  produced  when  com- 
plete cancerous  material  is  absorbed  into  the  blood,  or  when  secondary 
cancers  multiply  in  important  organs,  hindering  their  functions;  or  when 
ulceration  ensues  with  pain,  hemorrhage,  discharge,  and  hectic,  and  all 
the  various  signs  of  ruined  health.  When  these  things  are  added  to  the 
still  increasing  cancerous  condition  of  the  blood,  and  when  all,  with 
mutual  influence,  are  in  progress,  they  make  a  state  so  complex  that 
analysis  seems  impossible,  and  so  various  that  no  single  or  general  de- 
scription can  be  true.  The  general  result  is  what  is  commonly  called 
the  cancerous  cachexia ;  but  (as  I  have  said  before)  it  should  be  called 
the  secondary  cachexia,  to  distinguish  it  from  the  primary,  which  may, 
though  it  rarely  does,  precede  the  formation  of  a  cancerous  growth,  or, 
in  its  independent  increase,  may  far  exceed  the  probable  consequences 
of  the  local  disease  (pp.  553,  592).* 

The  constituents  of  the  secondary  cancerous  cachexia,  I  say,  are  too 
numerous  and  complicated  for  analysis  ;  still  we  must  always  recognize, 
in  the  later  stages  of  the  disease,  the  double  source  of  the  morbid 
phenomena;  namely,  the  progressive  constitutional  disease,  and  the 
effects,  direct  or  indirect,  of  the  local  disease.  How  nearly  indepen- 
dent the  former  is  of  the  latter  is  proved  by  the  results  of  removing 
the  local  disease.  The  secondary  cachexia  and  many  of  its  components 
may  be,  for  a  time,  decreased  ;  pain  and  discharge,  and  all  the  local 

*  The  induction  of  this  secondary  cachexia  by  the  presence  of  a  cancerous  tumor,  is  well 
illustrated  by  such  cases  as  sometimes  occur,  in  which  after  the  removal  of  the  tumor,  the 
general  health  remarkably  improves,  to  fail  again  when  recurrence  ensues,  and  again  to 
mend  after  the  second  removal.  See  a  case  by  Mr.  Jon.  Hutchinson,  Med.  T.  &  Gaz., 
July  16,  1853. 


NOSOLOGY    OF    CANCERS.  705 

accidents  of  the  disease,  may  cease :  but  the  average  lengthening  of 
life  is  not  great  (pp.  556,  594,  634).  The  fact  proves,  not  only  that 
the  progress  of  the  peculiar  constitutional  part  of  the  disease  is  nearly 
independent  of  the  local  part,  but,  also,  that  the  constitutional  part 
generally  contributes  most  to  the  fatal  issue.  However,  in  this,  as  well 
as  in  the  times  and  manners  of  dying,  and  the  times  of  recurrence 
after  removal  of  the  first  growths,  the  difference  in  the  several  forms 
of  cancer  are  such  as  should  not  be  put  out  of  sight  by  a  general  or 
summary  description  :  death  is  the  common,  and  almost  constant  end 
of  all,  but  its  circumstances  should  be  studied  separately  in  each. 

In  conclusion,  let  me  add  a  few  words  respecting  the  nosological 
relations  of  the  several  forms  of  cancer  to  one  another  and  to  other 
diseases. 

Here,  as  everywhere  in  pathology,  it  is  difficult  to  keep  the  just  mean 
of  classification ;  to  avoid,  on  the  one  side,  confusion ;  on  the  other,  too 
rigid  circumscription.  The  many  features  of  resemblance  in  all  the 
forms  of  cancer,  and  the  large  general  history  which  may  be  truly 
written  of  them,  might  lead  us  to  merge  all  minor  distinctions,  and 
speak  as  of  a  single  and  uniform  disease  ;  but  it  would  be  easy  to  show 
that,  if  in  this  view  we  write  of  the  general  symptoms,  progress,  and 
diagnosis  of  cancer,  or  of  the  history  of  cancers  in  any  single  organ, 
we  write  vaguely,  and  are  obliged  to  omit  many  points  of  importance, 
for  fear  of  contradictions.  If,  on  the  other  hand,  we  look  at  contrasts 
rather  than  likenesses,  we  might  be  induced  to  separate  some  forms,  as 
the  epithelial  and  colloid,  from  the  name  of  cancer,  and  to  believe 
that  the  remaining  forms  have  no  affinity  with  any  other  disease. 

I  suspect  that  the  errors  of  such  extremes  as  these  (in  all  nosology, 
as  well  as  in  that  of  cancers)  come  from  our  attaching  too  much  mean- 
ing to  the  terms  that  imply  specific  distinctions  among  diseases  ;  from 
our  proneness  to  think  of  them  as  if  they  meant  the  same  as  they  do  in 
zoology.  Now,  there  is  no  real  correspondence  between  the  two  sets 
of  terms.  A  specific  name,  in  zoology,  usually  implies  that  all  to  whom 
it  is  given  have  origin  from  a  common  stock ;  certain  characters  fixed, 
and  not  changeable,  beyond  certain  narrow  limits,  by  variety  of  external 
circumstances  ;  and  circumscriptions,  i.  e.  intervals  of  difference  be- 
tween them  and  other  species,  which  intervals  are  not  filled  up  by  varie- 
ties or  intermediate  forms.  Now  in  all  pathology,  there  are,  probably, 
no  such  species  as  these  ;  and  the  terms  implying  the  existence  of  genera, 
species,  and  varieties  of  disease,  mean  only  that  the  products  of  diseases 
may  be  arranged,  and  the  diseases  themselves  considered,  in  larger  and 
smaller  groups,  according  to  the  number  and  importance  of  the  charac- 
ters which  they  have  in  common.  Such  terms  do  not  mean  that  the 
borders  of  each  group  of  diseases  are  naturally  circumscribed  ;  they 
allow  that  the  borders  of  each  are  confused  with  those  of  every  ad- 
jacent group. 


706  GENERAL  PATHOLOGY  OF  CANCER. 

With  this  meaning,  I  have  adopted  the  terms  used  in  the  foregoing 
Lectures.  The  whole  group  of  diseases  included  under  the  name  (used 
like  a  generic  name)  of  Cancer  or  Carcinoma  are  sufficiently  dis- 
tinguished by  the  concurrence  in  them  of  all  the  characters  of  malig- 
nant tumors  enumerated  on  pages  843-347.  But  this  group  is  not 
circumscribed  ;  its  borders  are  everywhere  overlapped  by  those  of  dis- 
eases to  which  other  names  are  given :  there  are  no  one  or  two  charac- 
ters pathognomonic  of  cancer  and  found  in  it  exclusively.  The  fore- 
going Lectures  have  repeatedly  illustrated  this,  especially  in  the  ac- 
counts of  the  recurring  proliferous  cysts  (p.  386),  certain  cartilaginous 
tumors  (pp.  446,  459),  some  of  the  myeloid  (pp.  471,  510)  and  mam- 
mary glandular  (p.  492),  the  recurring  fibroid  and  fibro-nucleated  (pp. 
511,  517),  and  the  rodent  ulcers  (p.  621).  At  the  same  time,  this  want 
of  definition  in  the  assumed  genus  of  Cancers  has  been  exemplified,  it 
will  be  observed,  chiefly  by  rare  and  exceptional  cases ;  all  the  general 
facts  collected  in  the  Lectures  have  illjistrated  the  sufficiency  of  the 
concurrent  signs  of  cancer  for  a  ground  of  general  classification  (see 
p.  347). 

Among  the  difi"erent  forms  of  cancer,  I  have  already  said  (p.  638) 
that  there  appear  to  be  unequal  degrees  of  difference,  which  may  be  ex- 
pressed by  speaking  of  three  forms — namely,  the  scirrhous,  medullary, 
and  epithelial — as  species,  and  of  the  remainder  as  varieties,  of  cancer. 
All  that  has  just  been  said  of  the  want  of  circumscription  for  the  so- 
called  genus  will,  I  need  hardly  say,  be  applicable  to  these  smaller 
groups.  But  here  is  the  chief  point,  at  which,  while  avoiding  too  much 
precision,  we  must  also  guard  against  indifierence ;  for,  as  it  has  been 
wisely  said,  truth  is  more  likely  to  emerge  from  error  than  from  con- 
fusion. The  species  and  varieties  of  cancer,  as  of  other  diseases,  do 
not  correspond  with  those  of  living  creatures  ;  yet  the  difi"erences  of  the 
groups  thus  named  are  inconsistent  with  the  theory  of  a  single  unchang- 
ing disease  ;  and  I  believe  the  future  study  of  the  grounds  of  these  dif- 
ferences will  prove  very  fruitful  both  in  knowledge  and  in  practical 
utility. 

As  yet  we  can  only  speculate  upon  them  in  questions.  Do  they 
imply  so  many  essentially  and  originally  different  morbid  materials  ? 
or  is  there  one  material  for  cancer,  one  carcinogen,  which,  like  an  or- 
ganic radical,  may  form  different  yet  closely  allied  compounds,  in  its 
combinations  with  the  various  substances  provided  by  different  bloods, 
or  different  parts  ?  Is  not  this  hypothesis  more  appropriate  than  the 
first  for  the  less  usual  phenomena  of  transformation,  such  as  I  have 
described  as  occurring  in  the  progress,  succession,  and  hereditary  trans- 
mission of  the  cancerous  constitution  ?  Is  it  inconsistent  with  the 
gradual  fusion  of  the  characters  of  typical  cancer  in  those  of  other 
diseases  ? 


TUBERCLES    IN    THE    LUNGS.  707 

LECTURE    XXXV  L 

TUBERCLE. 

One  often  speaks  of  cancerous  and  other  tubercles,  meaning  only 
small  knots  or  knotted  masses  of  the  specified  morbid  growths  ;  and  of 
tubercular  cutaneous  eruptions,  meaning  small  circumscribed  flattened 
elevations  or  thickenings  of  the  cutis.  But  when  "tubercles,"  without 
any  specific  designation,  are  spoken  of,  the  word  is  always  understood 
to  refer  to  little  masses  of  a  peculiar  product  of  disease,  the  type  of 
which  is  found  in  the  lungs  as  the  essential  anatomical  constituent  of 
pulmonary  consumption  or  phthisis.  The  same  material  as  composes 
the  pulmonary  tubercles  is  found  in  many  different  forms  and  organs, 
and,  wherever  it  occurs,  is  described  as  "tubercle,"  or  "tuberculous 
matter;"  and  "tubercular  disease,"  or  "tuberculosis,"  is  the  usual  de- 
signation of  the  specific  diseases  of  which  the  essential  feature  is  the 
production  of  this  peculiar  matter. 

Tubercle  or  tuberculous  matter  may  be  formed  in  distinct  isolable 
masses,  around  which  the  adjacent  tissues  are  extended.  These,  which 
are  most  frequent  in  the  brain  and,  I  believe,  in  the  subcutaneous  tissue, 
may  be  like  tumors,  except  in  that  they  are  not  vascular,  and,  proba- 
bly, have  no  inherent  capacity  of  increase.  But  the  most  frequent 
formations  of  tuberculous  matter  are  in  infiltrations  of  the  natural  tis- 
sues, which  infiltrations  may  be  circumscribed,  having  definite,  though 
generally  irregular,  outlines,  or  diffuse,  i.  e.  widespread  and  indefi- 
nite.* 

In  the  lungs  (to  which,  on  account  of  its  exceeding  frequency,  we  are 
bound  to  look  for  its  type)  tuberculous  matter  appears,  as  Rokitansky 
says,  in  two  chief  varieties,  or  in  forms  combining,  or  intermediate  be- 
tween them.  These  are  generally  distinguished  as  the  "gray"  and 
the  "yellow"  tubercles;  or  the  gray  tuberculous  granulations,  and  the 
crude  tubercles.  It  may  also  appear  as  a  diffused  tuberculous  infiltra- 
tion, either  alone,  or,  more  frequently,  associated  with  the  preceding 
forms,  or  the  changes  consequent  on  them. 

The  gray  tubercles  appear  as  masses  about  as  large,  on  an  average, 
as  millet-seeds  (whence  their  name  of  miliary  tubercles),  imbedded  in 
the  substance  of  the  lungs.  They  are  usually  from  a  quarter  of  a  line 
to  a  line  in  diameter ;  and  when  the  lung  is  cut  through,  so  that  its 
elastic  tissue  can  recoil  and  subside,  they  appear  slightly  raised  on  its 
cut  surface,  and  the  finger  may  feel  them  as  little  firm  resisting  bodies 
set  in  the  lungs.     They  look  round  or  oval ;  but  their  borders  are  very 

*  The  name,  tuberculous  infiltration,  is  commonly  given  to  this  ditTiise  form  alone  ;  but 
in  the  miliary  and  other  tubercles,  even  in  the  lungs,  the  peculiar  materials  are  equally  in- 
filtrated among  the  natural  tissues ;  only,  in  these  the  infiltration  occupies  a  defined  area. 


708  TUBERCLES  IN  THE  LUNGS: 

irregular,  with  short  outrunning  processes.  They  are  gray,  semi-trans- 
parent, and  moderately  bright ;  or,  sometimes,  are  very  glistening,  with 
a  greenish-gray  "  cat's-eye"  tint.  In  the  latter  case,  they  may  look 
like  little  vesicles  ;  hut  they  are  always  solid.  They  may  be  discrete, 
i.  e.,  placed  singly,  and  with  distinct,  though  small,  intervals  in  the 
lung,  or  collected  in  groups.  They  occupy  and  involve  in  their  sub- 
stance the  tissues  of  the  lung,  and  are  so  connected,  that  portions  of 
these  tissues  always  adhere  to  them  when  we  try  to  separate  them. 
They  may  be  easily  broken  and  crushed,  and,  when  thus  treated,  they 
yield  but  little  fluid. 

The  yellow  tubercles  in  the  lungs  have  the  same  general  forms  and 
relations  as  the  preceding,  but  are  commonly  larger  and  less  firm,  and 
are  more  often  grouped  so  closely  that,  by  fusion,  they  make  up  nearly 
uniform  tubercular  masses,  half  an  inch  or  more  in  diameter.  They 
are  usually  pale  yellow,  or  yellowish-white,  opaque,  friable,  dry,  cheesy, 
smearing  the  surface  on  which  they  are  crushed.  Very  often,  their 
color  is  varied  with  a  smoky  gray  tint,  partly  due  to  intrinsic  change, 
and  partly  derived  from  the  pigment  of  the  lung  involved  by  them. 

It  has  been  generally  considered,  and,  indeed,  still  is  by  many  pa- 
thologists, that  the  two  varieties  of  pulmonary  tubercle  here  described 
represent  two  stages  of  the  same  disease ;  the  gray  substance  being, 
after  a  time,  changed  into  yellow.  Rokitansky,  however,  holds  that 
they  are  always  diiferent  substances ;  and  that,  though  they  may  be 
found,  side  by  side,  in  the  same  lung,  or  may  be  mingled  even  in  the 
same  tubercle,  yet  the  transformation  of  the  gray  into  the  yellow  sub- 
stance never  takes  place.  His  names  of  "simple  fibrinous"  applied  to 
the  gray  tubercle,  and  "  croupo-fibrinous"  to  the  yellow,  may  imply 
that  both  the  differences  and  the  aflSnities  between  the  two  forms  are 
comparable  with  those  between  the  two  chief  varieties  of  inflammatory 
lymph  (p.  233,  &c.). 

The  minute  structures  of  both  the  varieties  of  tubercle  are  essentially 
similar  ;  and  their  distinctive  characters  (in  the  state  in  which  they  ap- 
pear to  persist  longest)  are,  the  absence  of  bloodvessels  (except  of  such 
as  are  involved  in  the  deposit  and  not  yet  wasted),  and  the  defectively 
developed  or  aborted  statfe  of  the  blastema  and  the  corpuscles. 

The  blastema,  or  basis-substance,  of  a  tubercle  appears,  usually,  in 
fragments  or  flakes  of  a  moderately  firm,  clear,  or  dimly  molecular  sub- 
stance, swelling  and  made  clearer  by  acetic  acid.  It  is  most  abundant 
in  the  gray  tubercle,  most  molecular  or  dotted  in  the  yellow.  It  has  no 
filamentous  appearance,  no  trace  of  developing  nuclei  or  fibres. 

The  corpuscles  held  together  by  this  substance,  are  [a)  abundant  mi- 
nutest molecules,  granules,  and  oil-particles  of  various  but  usually 
small  size ;  all  these  being  extremely  predominant  in  the  yellow  tuber- 
cle ;  {h)  nuclei  or  cytoblasts,  of  various  shapes  and  apparent  structure, 
but  all  degenerate  or  defective ;  some  glittering,  hard-edged,  wrinkled, 
and  withered ;    others  granular ;    few  or  none  with  distinct  nucleoli : 


THEIR    CHIEF    FORMS.  709 

(c)  nucleated  cells,  similarly  misshapen,  withered,  or  granular ;  {d)  cer- 
tain compound  cells  described  below. 

Mingled  with  these,  and  varying  according  to  the  situation  and  cir- 
cumstances of  the  tubercles,  numerous  other,  but  accidental,  substances 
are  often  found :  namely,  {a)  the  involving  and  disintegrating  structures 
of  the  lung ;  membrane  or  elastic  fibres,  degenerate  epithelial  cells  of 
the  air-vesicles  or  minute  bronchi :  [h)  various  and  usually  degenerate 
products  of  inflammation  from  the  adjacent  parts,  granule-cells  and 
masses,  pus-cells,  &c. :  (c)  molecules  of  calcareous  matter,  or  of  pig- 
ment, and  crystals,  especially  of  cholesterine. 

Such  are  the  ordinary  constituents  of  pulmonary  tubercle,  and  the 
shrivelled  nuclei  and  imperfect  cells,  being  usually  the  most  abundant 
and  distinct,  are  called  tubercle-corpuscles.  Similar  materials  are  found 
composing  the  tuberculous  matter  in  other  parts.  In  the  lungs,  accord- 
ing to  Virchow*  and  Schroeder  van  der  Kolk,f  their  origin  may,  in  an 
earlier  stage,  be  traced  in  changes  of  the  epithelial  cells  of  the  air- 
vesicles. 

The  adjacent  copies  of  the  drawings  by  Schroeder  van  der  Kolk  may, 
with  his  description  of  them,  suffice  to  explain  the  process. 

"  The  margin  of  an  air-vesicle,  from  which  most  of  the  tubercle-cells 
are  removed,  is  shown  at  a  a  «;  that  of  another  adjacent  vesicle,  nearly 


a-  d 


filled  with  tubercle-cells,  at  III;  and  that  of  a  portion  of  a  third  vesi- 
cle, clear  of  tubercle-cells,  at  c.  At  d  the  still  unaffected  wall  of  the 
air-vesicle  is  shown  covered  with  epithelial  cells  of  various  sizes,  and 
containing  nuclei,  oil-drops,  and  granular  matter.  In  the  middle  and 
at  the  end  of  the  same  vesicle  are  some  cells  of  darker  tint ;  they  are 
no  longer  flat,  but  filled  with  some  material,  and  thereby  more  or  less 

*  Wiirzburg  Verhandlungen,  i,  81. 

f  Over  den  Oorsprong  en  de  Vorming  van  Tubercula  Puhnonum  :  Nederlandscli,  Lan- 
cet, 1852. 

\  Fig.  116.  Very  thin  section  of  a  portion  of  tuberculous  lung,  described  in  the  text. 
Magnified  420  times. 


710  TUBERCLES    IN    THE    LUNGS: 

swollen  or  spherical ;  they  are  epithelial  cells  more  or  less  distended 
with  fluid,  and  detached,  and,  as  the  series  of  them  shows,  they  con- 
stantly enlarge.  In  the  next  vesicle,  h,  these  cells  have  become  much 
larger,  and  are  closely  adherent.  It  is  observable  that  the  largest  cells 
commonly  lie  in  the  middle  of  the  cavity  of  the  air-cell :  the  larger  are 
mostly  filled  with  many  nuclei ;  in  the  smaller  there  is  but  one." 

"  It  is  thus  evident,  that  these  cells,  which  fill  the  air-vesicles  and 
make  up  the  tubercles,  are  nothing  else  than  epithelial  cells,  which  swell 
by  imbibition  of  plastic  matter,  enlarge,  and  are  detached  from  the  wall 
of  the  air-vesicle.  The  cells  which  are  placed  in  the  middle  of  the  vesi- 
cle are,  thus,  the  oldest,  i.  e.,  the  first  removed  from  the  walls,  the 
longest  exposed  to  the  influence  of  the  surrounding  fluid,  and  therefore 
the  largest.*  They  are  all  filled  with  granular  matter  and  minute  oil- 
spherules,  and  in  the  larger  an  increase  of  nuclei  has  taken  place." 

"If  tubercles  be  examined  in  a  somewhat  further  advanced  stage, 
when  they  show  more  tendency  to  softening,  the  larger  cells  just  de- 
scribed are  .found  in  much  less  quantity,  and  in 
place  of  them  the  air-vesicle  is  filled  with  smaller 
cells  [and  nuclei].  Among  these,  however,  some 
larger  cells  appear  (as  in  Fig.  117,  a)  containing 
smaller  cells  or  nuclei,  which  are  completely  like 
those  that  are  free  {h  b)  ;  so  that  there  can  be  no 
doubt  but  that,  in  this  state,  the  larger  corpuscles 
are  dissolved  or  burst ;  and  the  smaller  ones  set 
free."  These  smaller  cells  and  nuclei  set  free  are  what  have  been  gene- 
rally described  as  the  tubercle  corpuscles ;  and,  as  I  have  already  said, 
the  tuberculous  deposits,  after  the  earliest  periods  of  their  formation, 
may  appear  to  contain  no  other  formed  corpuscles  besides  them.  J 

*  In  the  College  Museum,  No.  297,  is  the  lung  of  a  Benturong  (Arctictis  Benturong), 
which  shows,  apparently  very  well,  this  progressive  accumulation  of  tuberculous  matter 
from  the  walls  to  the  centres  of  the  air-cells. 

f  Fig.  117.  Tubercle-corpuscles  :  magnified  420  times  and  described  in  the  text.  Copied 
from  Schroeder  van  der  Kolk. 

X  In  an  elaborate  paper  in  the  Br.  &  For.  Med.  Chi.  Rev.,  April,  1855,  On  the  Develop- 
ment of  Tubercle,  Dr.  C.  R.  Hall  states  that  the  formation  of  tubercle  in  the  lungs  is  accom- 
panied and  preceded  by  fatty  degeneration  of  many  of  the  epithelium-cells  of  the  air- vesicles. 
He  looks  upon  the  large,  many-nucleated  cells  as  modified  epithelium-cells,  but  does  not,  as 
Van  der  Kolk  seems  to  do,  limit  them  to  the  central  parts  of  the  cavities  of  the  air-cells. 
He  states  that  they  may  be  found  of  the  largest  size  and  containing  their  largest  number  of 
nuclei,  while  closely  adherent  to  the  wall  of  the  air- vesicle.  Neither  does  he  consider  that 
the  free  tubercle  corpuscles  are  solely  derived  from  the  nuclei  of  the  large  cells,  set  free  by 
the  bursting  of  the  walls,  but  that  the  proper  tubercle  corpuscles  are  mostly  formed  in  and 
from  the  plasma  exuded  into  the  air-vesicles.  Virchow,  however,  in  conformity  with  his 
views  that  the  corpuscles  of  pus  and  cancer  are  developed  from  the  pre-existing  cells  and 
nuclei  of  the  textures,  has,  by  carrying  out  the  same  methods  of  investigation,  traced  the  de- 
velopment of  tubercle  corpuscles  to  proliferating  changes  in  the  corpuscles  of  the  connective 
tissue  of  the  part  in  which  the  tubercle  arises.  (Cell.  Path.,  Lecture  XX.)  Ffirster,  also, 
has  illustrated  in  his  Atlas  (Taf.  xxxvi,  fig.  1)  the  development  of  tubercle  from  the  con- 
nective-tissue corpuscles  in  pulmonary  tuberculosis. 

In  a  recent  paper  in  Virchow's  Archiv  (xxiv,  p.  571),  Rindfleisch  has  traced  the  mode 


THEIR    CHIEF    FORMS.  711 

Now  the  most  peculiar  character  of  tuberculous  matter  which  these 
descriptions  illustrate,  is  its  early  degeneration,  its  abortiveness  ;  it  is 
shown  as  a  material  which,  after  proceeding  for  a  little  way  in  the  ac- 
quirement of  organic  structure,  then  stops  in  its  course,  recedes,  and 
degenerates.  This  is  evident,  at  once,  in  the  shrivelled  or  granular 
structure  of  the  set-free  nuclei  and  cells  ;  and  the  later  changes  are 
still  further  degenerative ;  all  prove  tuberculous  matter  to  be  not  only 
very  lowly  developed,  but  generally  incapable  of  development.* 

These  later  changes  may  be  again  illustrated  by  the  examples  of 
pulmonary  tubercle,  and,  according  to  Rokitansky,  may,  like  the  dif- 
ferences of  the  original  deposits,  be  compared  with  the  degeneration  of 
the  fibrinous  and  corpuscular  or  croupous  varieties  of  inflammatory 
lymph  (pp.  258,  262). 

(a)  The  withering  (obsolescence,  or  Verhornung  of  Rokitansky)  is 
the  peculiar  degeneration  of  the  gray  tubercle  in  the  lungs.  It  loses, 
herein,  its  lustre,  becomes  dry,  dense,  and  hard,  and  shrivels  into  a 
shapeless,  or  indistinctly  fibrous,  little  mass.  The  change  is  sometimes 
associated  with  a  calcareous  degeneration  of  the  tubercles,  and  often 
with  corresponding  changes  in  the  part  of  the  lung  in  which  they  are 
imbedded,  and  which  becomes  dry,  shrivelled,  and  dark  with  pigment. 

(b)  The  calcification,  or  calcareous  degeneration,  occurs  in  the  yel- 
low, and  in  the  mixed,  varieties  of  the  tuberculous  matter.  When 
achieved,  it  may  be  taken  as  an  indication,  like  the  withering  of  the 
gray  form,  that  the  tubercles  are  not  longer  subject  to  change  :  that 
they  are,  generally,  obsolete,  and  without  influence  on  the  tissues  around 
them.  It  may  occur  both  in  recent  yellow  tubercles,  and  in  such  as 
are  already  softened  ;  it  is  exactly  comparable  with  the  calcareous  de- 
generation of  inflammatory  lymph  and  pus,  and  is  usually  associated 
with  withering  and  pigmental  degeneration  of  the  surrounding  substance 
of  the  lung. 

(c)  The  softening  or  liquefaction  of  tuberculous  matter  is,  also,  ob- 
served only  in  the  yellow  and  mixed  varieties.  Though  more  studied 
in  tubercle  than  in  any  other  morbid  product,  it  is  not  peculiar  to  it, 
but  is  probably  analogous  with  many  other  liquefactive  degenerations, 
and  may  be  in  all  points  compared  with  that  of  inflammatory  lymph 

of  formation  of  the  cells  of  miliary  tubercle  in  a  case  of  acute  hydrocephalus.  He  found  the 
various  ramifications  of  the  arteries  of  the  pia  mater  studded  with  numerous  millet-seed  like 
granules,  and  he  traced  the  development  of  the  cells,  of  which  these  grannies  were  com- 
posed, from  the  nuclei  of  the  external  coat  of  the  arteries  to  which  they  were  connected. 

*  An  exception  to  this  statement  must  be  made,  for  certain  cases,  in  which  one  part  of 
what  seems  to  be  a  uniform  material  is  developed  into,  or  towards,  false  membrane,  and 
another  part  passes  through  the  degenerative  changes  of  tubercle.  Such  an  event  may  be 
seen,  according  to  Rokitansky  (vol.  i,  p.  409),  in  the  tuberculous  disease  of  the  peritoneum 
and  other  serous  membranes.  Schroeder  van  der  Kolk  represents  (as  in  fig.  116  b)  fila- 
ments of  rudimental  new-formed  tissue,  which,  he  says,  are  sometimes  found  among  the 
cells  of  pulmonary  tubercle.  In  tuberculous  peritonitis,  the  portion  of  material  developed 
into  false  membrane  may  become  vascular,  and  may  make  a  seeming,  though  not  a  real, 
exception  to  the  rule  of  the  nonvascularity  of  tuberculous  matter. 


712  TUBERCLES    IN    THE    LUNGS: 

(p,  259).  It  constitutes  the  so-called  tuberculous  suppuration,  and  pre- 
cedes the  formation  of  tuberculous  ulcers  and  cavities. 

The  process  of  softening  usually  commences  at  or  near  the  centre  of 
the  tuberculous  mass  ;  in  the  part  of  it  which,  we  may  believe,  being 
most  remote  from  blood,  is  least  able  to  maintain  itself  in  even  such 
low  development  as  it  may  have  reached.  The  central  softening  is  that 
which  is  spontaneous  and  normal  in  a  tubercle :  it  may  be  regarded  as 
a  natural  degeneration  of  the  morbid  substance ;  but  any  collection  of 
tuberculous  matter  may  also  be  softened,  at  its  periphery,  by  the  min- 
gling of  liquid  products  of  inflammation  in  the  adjacent  tissues.  The 
two  processes  of  softening  may  appear  similar,  and  may  coincide,  but 
they  are  essentially  distinct:  one  is  spontaneous,  the  other  accidental; 
in  the  one  the  liquid  material  is  the  very  substance  of  the  tubercle,  in 
the  other  it  is  derived  from  without. 

In  the  proper  softening  of  a  tubercle  one  sees  its  central  part  become, 
first,  soft,  so  that,  when  cut  across,  it  looks  cracked  and  crumbling, 
and  may  be  pressed  away  from  the  surrounding  firmer  part,  leaving  a 
little  central  cavity.  In  further  stage  of  the  degeneration,  it  becomes 
liquid,  like  thin  pus,  with  flakes  or  grumous  particles  in  a  pale  yellow- 
ish turbid  fluid  ;  and  as  the  change  makes  progress,  the  whole  tubercu- 
lous mass  may  be  reduced  to  the  same  liquid  state.* 

The  liquefied  tuberculous  matter  consists  of  the  lowest  of  the  corpus- 
cular materials  already  enumerated  (p.  708) ;  but  they  float  now  in  a 
liquid  containing  more  abundant  molecules  and  particles  of  oily  and 
calcareous  matter.  The  usual  sequence  of  the  liquefaction  is  the  dis- 
charge of  the  liquid,  by  ulceration  of  the  tissues  inclosing  it ;  but  if  the 
liquid  be  retained,  it  may  undergo  further  changes,  which  may  be  com- 
pared with  those  of  the  retained  contents  of  chronic  abscesses  (p.  273). 
The  chief  are,  that  its  fluid  parts  are  gradually  absorbed,  and  its  fatty 
and  calcareous  matters  increase,  till  it  becomes  a  dry,  greasy,  crum- 
bling, or  gradually  hardening,  mortar-like  concretion. 

The  discharge  of  a  quantity  of  liquefied  tuberculous  matter,  by  ul- 
ceration through  an  adjacent  bronchus,  or  through  the  integuments  of 
a  subcutaneous  tuberculous  lymphatic  gland  (for  example),  leaves  a 
cavity,  vomica,  or  abscess ;  when  the  discharge  takes  place  from  single 
small  tubercles,  such  as  form  beneath  the  surface  of  the  mucous  mem- 
brane of  the  intestinal  canal,  an  ulcer  remains;  and  these  are,  severally, 
sufiiciently  peculiar  in  their  characters  to  be  known  as  the  tuberculous 
cavity,  and  tuberculous  ulcer. 

The  ulceration  eff"ecting  the  discharge  is  usually  the  consequence  of 
inflammation  in  the  tissues  over  the  tuberculous  matter,  and  resembles 
that  for  the  discharge  of  common  pus.  By  similar  inflammatory  ul- 
ceration of  its  boundaries,  the  tuberculous  cavity  or  ulcer  may  be  en- 

*  Such  changes  may  be  seen  better,  I  think,  in  the  tubercles  in  the  spleen  than  in  those 
in  any  other  part:  Mus.  St.  Bartholomew's,  Ser.  xxii,  2,  3. 


TUBERCULOID    S  U  B  ST  A  IsT  C  E  S.  713 

larged:  but  more  generally,  and  more  normally,  its  enlargement  is  due 
to  the  formation  and  discharge  of  fresh  tuberculous  deposits  adjacent 
to  it.  This  may  be  best  seen  in  tuberculous  ulcers  of  the  intestines ; 
but  the  same  process  occurs  at  the  cavities  in  such  parts  as  the  lun<TS 
and  lymphatic  glands.  At  the  borders  and  bases  of  the  cavity  or  ulcer 
one  may  often  find  small  secondary  tubercles,  which,  following  the  same 
course  as  the  primary,  liquefy,  and  are  discharged  into  the  cavity,  or 
on  the  surface  of  the  ulcer,  which  they  thus  increase  by  adding  their 
cavities  to  it.  Other  tubercles,  again,  may  succeed  to  these,  and  pass 
through  the  same  changes ;  and  when  many  cavities  and  ulcers  are 
thus  simultaneously  enlarging,  they  come  into  collision,  and  two  or 
more  are  fused  into  one  of  sometimes  vast  dimensions. 

In  these  changes,  the  tissue  involved  in  the  tuberculous  deposits 
(whether  primary  or  later)  soften,  and  are  disintegrated  and  discharged 
with  them.  There  is  thus,  always,  a  loss  of  substance  in  the  affected 
part,  coextensive  with  the  tuberculous  cavity.  But,  the  bordering 
tissues,  if  not  tuberculous,  may  be  infiltrated  with  organizable  inflam- 
matory lymph,  which,  in  its  development,  may  form  a  tough  boundary 
to  the  cavity  or  ulcer,  and,  if  fresh  tuberculous  matter  be  not  deposited 
in  it,  may  lead  to  complete  healing. 

Before  illustrating  the  foregoing  general  account  of  tuberculous  mat- 
ter, and  of  its  principal  changes,  by  some  of  the  instances  which  are 
chiefly  interesting  in  surgical  pathology,  it  may  be  well  to  speak  of 
some  afiections  which  have  an  apparent  or  real  affinity  with  it. 

Degenerative  changes,  similar  to  those  which  ensue  in  the  lowly 
developed  materials  of  tubercle,  may  produce  a  similar  appearance  in 
other  materials, — especially  in  those  which  consist  of  cells,  or  rudi- 
ments of  cells.  Thus,  it  is  common  to  find,  in  medullary  cancers,  and 
more  rarely  in  others,  portions  of  yellow,  half-dry,  crumbling,  and 
cheesy  substance,  so  like  tubercle  that,  with  the  naked  eye,  they  can 
hardly  be  distinguished  from  it.  The  cancers  in  which  they  occur  have 
been  described  as  mixtures  of  cancerous  and  tuberculous  matters ;  but 
the  microscope  finds  that  the  tuberculoid,  or,  as  M.  Lebert  calls  it,  the 
phymatoid,  material  in  them  consists  of  cancer-corpuscles  withered, 
with  fatty  and  calcareous  degeneration,  and  mingled  with  molecular 
and  granular  matter.  By  similar  degeneration,  material  like  tubercle 
may  be  found  in  cartilaginous,  rudimental  fibro-cellular,  and  probably 
other,  tumors.  In  all  these  instances,  the  microscope  may  usually 
insure  a  just  diagnosis,  and  may  prove  that  the  tuberculous  appearance 
is  only  due  to  a  withering  and  a  fatty  degeneration  of  materials  that 
have  nothing  but  their  degeneration  in  common  with  true  tuberculous 
matter.* 

*  Virchow  (Wiirzburg  Abhandl.,  B.  i,  ii,  iii)  had  proposed  to  speak  of  the  change,  in  all 
these  cases,  as  a  "tuberculous  metamorphosis,"  or  "tuberculization,"  and  was,  of  course, 
misunderstood,  as  if  he  had  implied  that  every  material  may  become  tuberculous  matter. 

46 


714  TUBERCULOID  SUBSTANCES. 

Greater  difficulty  of  diagnosis  exists  when,  through  similar  degenera- 
tion, inflammatory  lymph  assumes  the  appearance  of  tuberculous  mat- 
ter. It  does  so,  sometimes,  in  chronic  inflammation,  or,  when  acute 
inflammation  has  subsided,  in  lymphatic  glands,  in  the  testicle,  and,  I 
believe,  in  some  other  parts.  So,  too,  if  the  pus  of  chronic  abscesses 
or  other  suppurations  is  not  discharged,  it  may  gradually  dry ;  and  as 
its  corpuscles  wither,  with  fatty  and  calcareous  degeneration,  it  may 
assume  an  appearance  very  like  that  of  tuberculous  matter.  And,  in 
all  these  cases,  the  resemblance  may  extend  equally  to  the  microscopic 
characters  ;  so  that  there  are,  I  believe,  no  signs  by  which  degenerate 
lymph  or  pus  may  be,  in  all  cases,  distinguished  from  ordinary  tuber- 
culous matter.  When,  as  in  the  cases  cited  on  page  263,  the  lymph- 
cells  have  been  developed  and  elongated  before  their  degeneration,  they 
may  be  known  from  any  corpuscles  of  tubercle ;  and'  the  many-nucle- 
ated cells  in  tuberculous  disease  may  be  distinguished  from  the  ordi- 
nary products  of  inflammation ;  but  neither  of  these  forms  may  exist, 
and  then  I  believe  that  a  distinction  of  degenerate  lymph  from  tubercle 
may  be  impossible.  Certainly,  it  is  often  very  difficult  to  say  whether 
the  yellow,  dry,  and  cheesy  material,  found  in  chronic  enlargements  or 
suppurations  of  lymphatic  glands,  should  be  regarded  as  tuberculous 
matter,  or  as  withered  and  degenerate  lymph  or  pus  produced  by  in- 
flammation. The  same  difficulty  may  exist  in  the  similar  affections  of 
the  testicles ;  but  in  these,  more  than  in  the  case  of  the  lymphatic 
glands,  we  may  be  extremely  doubtful  of  any  material  being  really  tu- 
berculous, if  it  be  found  in  them  alone,  and  not  at  the  same  time  in 
other  parts  of  the  genital  apparatus,  or  in  the  lungs.  Similar  difficul- 
ties may  exist  in  the  diagnosis  between  tubercle  and  some  instances  of 
chronic  pneumonia.* 

Thus,  then,  there  are  not  a  few  cases  in  which  materials  like  those 
of  tubercles  are  found  as  results  of  diseases  that  are  not  tuberculous  ; 
^.  e.  that  are  neither  coincident  with,  nor  according  to  the  type  of, 
tuberculous  disease  in  the  lungs.  And  the  difficulty  hence  arising  is 
increased  by  this :  that  both  tuberculous  products,  and  the  varieties  of 
degenerate  and  withered  lymph  and  pus,  are  especially  frequent  among 
persons  of  the  "  scrofulous"  or  "strumous"  constitution;  so  that  the 
degenerate  lymph  and  pus  are  often  described  as  "  scrofulous  matter;" 
and  "scrofula"  and  "tuberculous  disease"  are  often  regarded  as  the 
same  disease. 

It  is,  I  fear,  impossible  to  clear  the  confusion  arising  from  the  inter- 
changing uses  of  these  terms,  or  to  define  exactly  the  cases  to  which 
they  should  severally  be  applied  ;  but  where  definition  of  terms  is  im- 

He  suggests,  now,  that  the  change  by  which  so  many  essentially  different  things  may  be- 
come "  cheesy,"  should  be  called  "  the  eheesy  metamorphosis." 

*  Virchow  has  written  fully  on  this  point ;  and  a  clear  statement  of  his  and  others' 
opinions,  respecting  the  different  forms  of  pulmonary  phthisis,  is  given  by  Dr.  Jenner  in  the 
Br.  and  For.  Med.  Chir.  Review,  Jan.,  1853. 


SCROFULOUS    OR    STRUMOUS     DISEASES.  715 

possible,  the  next  best  thing  is  an  understanding  of  their  meaning 
according  to  general  usage.  "  Scrofula,"  or  "  struma,"  then,  is  gene- 
rally understood  as  a  state  of  constitution  distinguished,  in  some  mea- 
sure, by  peculiarities  of  appearance  even  during  health,  but  much  more 
by  peculiar  liability  to  certain  diseases,  including  pulmonary  phthisis. 
The  chief  of  these  "  scrofulous"  diseases  are  various  swellings  of  lym- 
phatic glands,  arising  from  causes  which  would  be  inadequate  to  pro- 
duce them  in  ordinary  healthy  persons.  The  swellings  are  due,  some- 
times, to  mere  enlargement,  as  from  an  increase  of  natural  structure ; 
sometimes  to  chronic  inflammation  ;  sometimes  to  more  acute  inflamma- 
tion, or  abscess  ;  sometimes  to  tuberculous  disease  of  the  glands.  But, 
besides  these,  it  is  usual  to  reckon  as  "  scrofulous"  affections  certain 
chronic  inflammations  of  joints  ;  slowly  progressive  "carious"  ulcera- 
tions of  bones  ;  chronic  and  frequent  ulcers  of  the  cornea  ;  ophthalmia 
attended  with  extreme  intolerance  of  light,  but  with  little  if  any  of  the 
ordinary  consequences  of  inflammation ;  frequent  chronic  abscesses ; 
pustular  cutaneous  eruptions  frequently  appearing  upon  slight  afl"ec- 
tion  of  the  health  or  local  irritation ;  habitual  swelling  and  catarrh  of 
the  mucous  membrane  of  the  nose  ;  habitual  swellings  of  the  upper  lip. 

Now  these,  and  many  more  diseases  of  the  like  kinds,  are,  amongst 
us,  both  in  medical  and  in  general  language,  called  scrofulous,  or  stru- 
mous ;  but,  though  many  of  them  are  often  coincident,  yet  it  is  very 
difficult  to  say  what  all  have  in  common,  so  as  to  justify  their  common 
appellation.  Certainly  they  are  not  all  tuberculous  diseases.  Little 
more  can  be  said  of  them  than  that,  as  contrasted  with  other  diseases 
of  the  same  forms  and  parts,  the  scrofulous  diseases  are  usually  dis- 
tinguished by  mildness  and  tenacity  of  symptoms  :  they  arise  from  ap- 
parently trivial  local  causes,  and  produce,  in  proportion  to  their  duration, 
slight  eff"ects  :  they  are  frequent,  but  not  active.  The  general  state  on 
which  they  depend  may  be  produced  by  defective  food,  with  ill  ventila- 
tion, dampness,  darkness,  and  other  depressing  influences ;  and  this 
general  state  of  constitution,  whether  natural  or  artificially  generated, 
is  fairly  expressed,  by  such  terms  as  "  delicacy  of  constitution,"  "gene- 
ral debility,"  "  defective  vital  power,"  "irritability  without  strength." 
Such  terms,  however,  do  not  explain  the  state  that  they  express,  for 
they  all  assume  that  there  are,  in  human  bodies,  different  degrees  of 
vital  power,  independent  of  differences  of  material ;  which  is  at  least 
not  proved. 

Such  is  the  vagueness  of  "  scrofula,"  and  of  the  terms  derived  from, 
it,  as  commonly  used  in  this  country.  They  include  some  diseases 
which  are,  and  many  which  are  not,  distinguished  by  the  production  of 
tuberculous  matter.  It  has  been  proposed,  but  I  doubt  whether  it  be 
practicable,  to  make  "scrofulous"  and  "tuberculous"  commensurate 
terms  :  as  at  present  generally  employed,  the  former  has  a  much  larger 
import  than  the  latter.  The  relation  between  the  two  is,  that  the 
"scrofulous"  constitution  implies  a  peculiar  liability  to  the  tuberculous 


716  TUBERCULOUS     DISEASE    OF    LYMPHATIC     GLANDS. 

diseases  ;  and  that  they  often  coexist.  Their  differences  are  evident  in 
that  many  instances  of  scrofula  (in  the  ordinary  meaning  of  the  word) 
exist  with  intense  and  long-continued  disease,  but  without  tuberculous 
deposit ;  that  as  many  instances  of  tuberculous  disease  may  be  found 
without  any  of  the  non-tuberculous  affections  of  scrofula;  that,  as  Mr. 
Simon  has  proved,  while  the  disease  of  "defective  power"  may  be  ex- 
perimentally produced  in  animals  by  insufficient  nutriment  and  other 
debilitating  influences,  the  tuberculous  diseases  are  hardly  artificially 
producible ;  that  nearly  all  other  diseases  may  coexist  with  the  scrofu- 
lous, but  some  are  nearly  incompatible  with  the  tuberculous. 

Now,  whether  we  disuse,  or  still  use  in  its  vagueness,  the  term  scro- 
fula, we  may  make  a  group  of  the  "  tuberculous"  diseases,  defined  by  the 
peculiar  morbid  product,  of  which  I  have  described  the  chief  characters. 
Only,  at  present,  we  must  be  content,  I  believe,  to  be  sometimes  in 
doubt  whether  the  substance  found  in  lymphatic  glands,  and  commonly 
known  as  scrofulous  matter,  be  trully  tuberculous  matter,  or  degenerate 
lymph  or  pus. 

•The  Lymphatic  Glands,  among  the  parts  specially  studied  in  surgi- 
cal pathology,  hold  the  first  place  in  liability  to  tuberculous  disease. 
In  children,  they  are,  even  more  often  than  the  lungs,  primarily 
afi"ected ;  in  adults,  they  are  next  to  the  lungs  in  the  order  of  fre- 
quency ;  and  in  all  ages,  whatever  part  becomes  tuberculous,  the  lym- 
phatic glands  in  relation  with  it  are  apt  to  be  similarly  affected. 

The  glands  most  often  primarily  tuberculous  are  the  bronchial,  mesen- 
teric, cervical,  and  lumbar.  Their  state,  previous  to  the  tubercular 
formation,  may  seem  healthy  ;  or  they  may  be  simply  enlarged  ;  or 
signs  of  inflammation  may  precede  and  accompany  the  deposit.  E,oki- 
lansky  says  that,  in  some  cases,  the  tuberculous  matter,  as  in  the  gray 
^pulmonary  tubercles,  appears  in  small  round  masses  of  grayish  sub- 
. stance.  But  its  far  more  frequent  appearance  in  the  glands  is,  like 
the  yellow,  pulmonary  tuberculous  matter,  in  the  form  of  roundish  or 
irregular  deposits  of  yellowish,  opaque,  half-dry,  cheesy,  crumbling 
substance.  Such  deposits  are  infiltrated  among  the  proper  textures  of 
the  glands.  At  first  discrete,  and  contrasting  strongly,  both  in  sub- 
stance and  in  color,  with  the  unaffected  portions  of  the  gland,  they 
gradually  increase,  till  they  may  completely  displace  the  natural  struc- 
ture, with  its  bloodvessels,  or  leave  only  a  thin  outer  layer  of  it  in- 
closing the  yelloAV  mass  which  they  form.  By  the  increase  of  the 
tuberculous  matter,  as  well  as  by  the  swelling  of  their  proper  textures, 
the  glands  are  usually  enlarged ;  they  may  acquire  even  an  enormous 
volume,  and,  when  whole  series  of  them  are  afi"ected,  may  construct 
great  lobed  and  nodular  swellings.  In  all  cases,  however,  the  several 
glands  maintain  a  kind  of  independence  ;  so  that  one  may  enlarge  while 
others  diminish,  and  one  or  more  may  inflame  or  suppurate ;  while,  in 
others,  the  tuberculous  matter  remains  stationary,  or  retrogrades. 


TUBERCULOUS     DISEASE    OF    LYMPHATIC    GLANDS.        717 

The  minute  structures  in  tubercle  of  the  lymphatic  glands  are  essen- 
tially similar  to  those  described  from  examples  in  the  lungs  :  and  Vir- 
chow*  has  found  that,  in  the  first  stage  of  the  process,  there  is  an  endo- 
genous increase  of  nuclei  within  the  elementary  structures,  similar  to 
that  which  I  have  described  after  Schroeder  van  der  Kolk.  The  same 
softening  and  liquefaction,  also,  as  in  the  lungs,  is  prone  to  ensue  in 
the  lymphatic  glands. 

The  softening  is  usually  central,  and  thence  extending  may  affect  the 
whole  morbid  substance.  The  result  of  the  change  is  not  a  homoge- 
neous liquid ;  but,  rather,  a  mixture  of  thin,  turbid,  yellowish- white 
liquid,  and  portions  of  soft  curd-like,  cheesy  substance,  like  fragments 
of  tubercle  softened  by  imbibed  fluid.  To  these  are  commonly  added 
the  liquid  products  of  the  inflammation  of  whatever  remains  of  the 
gland-substance,  or  its  capsule,  and  the  surrounding  parts.  The  mix- 
ture constitutes  the  tuberculous,  or,  as  it  is  generally  called,  scrofulous 
pus,  of  which  the  chief  characters,  as  distinguis.hed  from  those  of  ordi- 
nary inflammatory  pus,  are,  that  it  has  an  abundant  thin,  yellowish, 
and  slightly  turbid  liquid,  with  white,  curdy  flakes  that  quickly  subside 
when  it  is  left  at  rest. 

The  liquefaction  of  the  tuberculous  matter  in  the  glands  usually  leads 
to  its  discharge ;  and  this  is  effected,  in  the  case  of  the  cervical  and 
other  similarly  placed  glands,  by  ulceration,  which  differs  from  that  for 
the  opening  of  common  abscesses,  chiefly,  in  being  slower,  and  attended 
with  less  vivid  and  less  concentrated  inflammation.  There  is,  therefore, 
less  disposition  to  point :  the  skin  is,  proportionally,  more  widely  under- 
mined, more  extensively  thinned.  Thus  gradually,  by  thinning  and  in- 
flammation, deprived  of  blood,  the  inflamed  skin  over  the  tuberculous 
gland  whose  contents  are  liquefied,  may  perish,  and  form  a  dry  parch- 
ment-like slough,  very  slowly  to  be  detached.  More  commonly,  how- 
ever, one  or  more  small  ulcerated  apertures  form  in  the  skin,  and  let 
out  the  fluid.  If  the  undermined  skin  be  freely  cut,  its  loose  edges  are 
apt  to  ulcerate  widely  ;  if  it  be  only  punctured  and  allowed  to  subside 
gradually,  it  usually  contracts  and  recovers  its  healthy  state. 

The  cavity  left  by  the  discharge  of  the  liquefied  tuberculous  matter, 
and  of  the  fluids  mingled  with  it,  may  heal  up  like  that  of  an  ordinary 
abscess;  but  it  does  so  slowly,  and  often  imperfectly,  inclosing  portions 
of  tuberculous  matter,  which  soften  at  some  later,  and  often  at  some 
distant,  period,  and  lead  to  a  renewal  of  the  process  for  discharge. 
However,  such  retained  portions  of  tubercle,  or  even  the  whole  of  what 
has  been  formed,  and  perhaps  liquefied,  in  a  lymphatic  gland,  instead 
of  being  discharged,  may  degenerate  further,  and  be  absorbed  ;  or  may 
wither  and  dry  up  into  a  fatty  and  calcareous  concretion.  Such  chalky 
masses,  even  of  large  size,  are  frequently  found  in  bronchial  and  mesen- 
teric glands  that  have  been  seats  of  tuberculous  disease  in  childhood  ; 

*  Wiirzburg  Verhandlungen,  i,  84. 


718  TUBERCULOUS     ULCEES     OF    THE     INTEGUMENTS. 

and  similar  material,  but  usually  in  small  fragments,  is  often  discharged 
from  healing  tuberculous  abscesses  in  the  neck. 

Whether  by  healing  after  discharge,  or  by  calcification  of  the  re- 
tained tuberculous  matter,  the  recovery  from  the  primary  tuberculous 
disease  of  the  lymphatic  glands  is  often  complete  and  permanent.  The 
original  substance  of  the  gland  may  be  wholly  destroyed ;  or  portions 
of  it  may  remain  indurated  and  fixed  closely  to  the  scar  or  the  calca- 
reous concretion. 

I  am  not  aware  that  tubercle  is  ever  seen,  primarily,  in  lymphatic 
vessels  ;  but  it  may  be  often  traced  in  those  of  the  intestines  and  mesen- 
tery that  are  in  relation  with  tuberculous  ulcers  involving  the  muscular 
and  subperitoneal  tissues. 

I  am  not  aware  that  tubercular  deposits  have  been  proved  to  be  the 
origin  of  the  so-called  scrofulous  ulcers  of  the  integument ;  but  that 
they  are  so  is  highly  probable,  seeing  that  such  ulcers  sometimes  super- 
vene at  the  openings  for  discharge  of  liquefied  tubercle  from  lymphatic 
glands,  and  that,  in  many  characters,  they  remarkably  resemble  the 
tuberculous  ulcers  of  the  mucous  membrane  of  the  intestines. 

The  ulcers  for  which  we  may  suspect  a  truly  tuberculous  origin  are 
most  frequent  in  the  neck,  at  the  sides  of  the  face,  at  the  upper  part  of 
the  chest,  and  on  the  arms.  They  are  sometimes  preceded  by  the  for- 
mation of  one  or  more  small  oval  masses  of  firm  substance  in  the  sub- 
cutaneous tissue  :  these,  passing  through  the  usual  changes  of  suppu- 
rating tuberculous  glands,  discharge  themselves ;  and  the  ulceration 
extends  from  the  aperture  of  discharge.  But,  more  often,  the  ulcers 
commence  in  patches  of  skin  which,  Avith  the  subcutaneous  tissue,  have 
appeared  for  some  days  or  weeks,  inflamed,  thickened,  and  slightly  in- 
durated. Central  softening  and  liquefaction  ensue  in  these  ;  the  cutis 
is  gradually  undermined,  and  then  ulcerates,  letting  out  a  small  quan- 
tity of  thin,  flaky,  and  turbid  fluid,  like  that  of  liquefied  tubercle.  The 
ulcers  thus  formed  have  generally  destroyed  the  thickness  of  the  cutis. 
They  are  of  various  shapes  ;  most  often  elongated  oval,  but  sometimes 
round,  or  sinuous ;  more  rarely  annular,  or  crescentic ;  very  rarely 
quite  regular  in  shape.  Their  margins  are  usually  (if  they  are  not 
quickly  extending)  undermined,  rounded,  thickened,  and  unequal.  The 
skin  upon  and  around  their  margins  is  pale  rose-pink ;  or  tends,  accord- 
ing to  the  activity  or  torpor  of  the  disease,  towards  florid  redness,  or  a 
pale  livid  hue.  Their  bases  are  unequal,  often  nodular,  or  tuberculated, 
pale,  with  unequal  or  succulent  granulations;  they  yield  a  thin,  turbid, 
whey-like  fluid,  which  may  concrete  in  scabs,  and  sometimes  irritates 
the  parts  on  Avhich  it  lies.  They  have  no  proneness  to  extend  much  in 
depth ;  neither  do  they  extend  widely,  unless  acute  inflammation  super- 
vene at  their  boundaries ;  rather,  their  tendency  is  to  remain  long  sta- 
tionary, or  partially  healing  ;  or,  while  some  are  healing,  others  may 
be  progressive. 


TUBERCULOUS    DISEASES    OF    BONES.  719 

The  scar  formed  in  the  healing  of  these  ulcers  is  peculiar,  resembling 
that  of  the  healed  tuberculous  ulcers  of  the  mucous  membrane  of  the 
intestines.  It  is  formed  of  very  tough  tissue,  which  remains  long  fixed 
to  the  subjacent  structures,  and  of  which  the  surface  is  generally 
colored  with  vascular  congestion,  seen  through  the  thin  covering  of  new 
cuticle.  But,  chiefly,  the  surfaces  of  such  scars  are  deeply  seamed  and 
wrinkled ;  or  have  prominent  hard  ridges  that  tend  towards  their  cen- 
tres, or  across  their  axes.  The  cutis  that  surrounds  the  ulcers  is  very 
much  contracted  in  the  formation  of  the  scars :  and  both  in  this  re- 
spect, and  the  abundant  tough  tissue  constructing  them,  they  may  be 
likened  to  the  scars  following:  burns. 

Among  the  Bones,  tuberculous  disease  affects  most  frequently  those 
of  spongy  cancellous  tissue ;  such  as  the  tarsal  and  carpal,  the  verte- 
brge,  the  phalanges,  and  the  expanded  articular  portions  of  larger  bones, 
especially  of  the  femur,  tibia,  humerus,  and  ulna.  When  it  aflFects 
bones  that  are  arranged  in  a  group  or  series,  it  is  usually  found  in  many 
of  them  at  once.  Thus,  several  vertebrae,  or  several  carpal  or  tarsal 
bones,  are  commonly  at  the  same  time  tuberculous;  yet  not  often  so 
equally,  but  that  one  of  them  appears  first  and  chiefly  diseased ;  while, 
in  those  gradually  more  distant  from  it  on  either  side,  the  tuberculous 
deposits  are  gradually  less  abundant.  In  like  manner,  the  parts  of 
bones  that  act  together  in  a  joint  are,  usually,  at  the  same  time  tuber- 
culous. 

Rokitansky  says  that  gray  tuberculous  matter  may  be  found,  about 
tuberculous  suppurations  in  bone,  in  the  form  of  granulations  seated  in 
the  medullary  membrane.  The  usual  appearance  is  that  of  yellow,  soft, 
cheesy  deposits,  or  infiltrations  of  tubercle.  The  infiltration  may  be 
either  circumscribed  or  diff"use  :  and,  in  these  differences,  generally  cor- 
responds with  the  similar  varieties  in  the  lungs;  especially  in  that, 
usually,  the  circumscribed  infiltrations  take  place  with  scarcely  any 
signs  of  inflammatory  disease,  while  the  diffuse  are  preceded  and  accom- 
panied by  all  the  signs  and  effects  of  slowly  progressive  inflammation 
of  the  bone. 

In  the  circumscribed  infiltrations,  the  tuberculous  matter  usually 
forms  round,  or  oval  masses,  which  are  imbedded  in  cavities  in  the  in- 
terior of  the  bones.  A't  these  cavities,  several  of  which  may  exist  near 
together,  the  normal  textures  of  the  bone  appear  to  be  disintegrated  or 
absorbed,  just  as  those  of  the  lung  are  during  the  infiltration  of  the 
tuberculous  matter  among  them.  When  the  liquefaction  of  the  tubercle 
takes  place,  a  similar  imitation  of  the  formation  of  cavities  in  the 
lungs  is  noticeable.  The  usual  thin  puriform  fluid  is  produced,  and  is 
often  mixed  with  little  fragments  of  bone.  The  bony  cavity  including 
it  commonly  becomes  lined  by  a  thin,  smooth,  closely  adherent  mem- 
brane,— the  product,  apparently,  of  ordinary  inflammation.  Appear- 
ances are  thus  attained,  especially  in  the  bodies  of  vertebrae,  like  those 


720  TUBERCULOUS    DISEASES     OF    BONES. 

of  numerous  small  chronic  abscesses  in  bones  :  and  similar  cavities  may 
be  found  between  the  bone  and  periosteum,  when  the  tuberculous  matter 
has  been  formed  between  them,  or  has  included  the  surface  of  the  bone 
in  its  infiltration.  The  liquid  contents  of  the  cavities  may  be  discharged 
through  narrow  apertures  in  the  walls  of  the  bone,  or  other  surround- 
ing parts ;  but,  commonly,  a  more  diffuse  inflammatory  or  tuberculous 
formation  ensues,  destroying  both  the  walls  of  the  cavities  and  their 
boundaries. 

The  diffuse  infiltration  of  tuberculous  matter  in  bone  may  be  the 
form  assumed  from  the  first,  or  it  may  supervene  on  the  preceding.* 
The  deposits  observe  no  definite  shape :  they  fill  the  cancellous  spaces 
in  the  bone,  displacing  the  medulla,  and  either  leaving  the  osseous  tis- 
sue entire,  or  softening  and  disintegrating  it,  so  that  small  fragments, 
or  larger  sequestra,  appear  mixed  with  the  crumbling  tubercle.  The 
abundant  deposit  of  tubercle,  and  the  fulness  of  the  vessels  of  the  in- 
flamed and  softening  bone,  make  the  swelling  in  this  form  more  con- 
siderable than  in  the  preceding.;  yet  it  is  rarely,  if  ever,  great.  The 
liquefaction  is  attended  with  larger  and  more  destructive,  though  slow, 
ulceration  of  the  bone  ;  and  is  followed  by  discharge  of  the  fluid  to- 
gether with  products  of  inflammation,  through  many  apertures,  or  from 
a  widely  ulcerated  surface.  The  bone  bounding  such  ulceration  is, 
moreover,  commonly  inflamed,  if  not  tuberculous  ;  and  thus  the  ulcera- 
tion may  constantly  make  progress  in  depth  and  width,  imitating  the 
types  of  tuberculous  ulceration  already  described,  in  that  the  destruc- 
tion is  of  twofold  character  :  due  partly  to  secondary  formations  and 
liquefactions  of  tubercle,  and  partly  to  continued  bordering  inflamma- 
tion. 

The  changes  produced  by  circumscribed  tuberculous  deposits  in  bone 
are,  comparatively,  seldom  seen  ;  for  the  disease  is  of  slow  progress, 
and  rarely  leads  to  death,  or  amputation,  before  the  more  diffuse  ulcera- 
tion has  supervened  and  destroyed  its  characteristic  features.  The  dif- 
fuse disease  is  therefore  that  which  has  been  most  studied,  and  which 
has  supplied  most  of  the  examples  of  "scrofulous  caries,"  "Pott's  dis- 
ease of  the  spine,"  "Psedarthrocace,"  &c.  It  is  this,  also,  which  is 
chiefly  attended  with  suppurations,  or,  perhaps,  tuberculous  deposits, 
in  the  neighborhood  of  the  diseased  bone. 

The  tuberculous  diseases  of  bone  are,  comparatively,  rarely  healed. 
Mr.  Stanley  has  well  shown  that  the  completely  curable  cases  of 
"scrofulous"  disease  in  bone  are  those  in  which  "the  changes  have 
not  passed  beyond  those  of  simple  inflammation  :"  ^.  e.,  of  such  inflam- 
mation as  commonly  precedes  the  diffuse  deposit  of  tubercle.  When 
tubercle  is  deposited  in  bone,  its  usual  course  is,  as  in  other  parts,  only 
degenerative :  it  may  liquefy,  or  calcify  :  it  is,  probably,  never  organ- 

■^  The  two  forms  are  illustrated  in  the  College  Museum,  Nos.  854-5;  and  in  that  of  St. 
Bartholomew's  in  Series  I,  37,  38,  39,  70,  103,  &c. 


AFFINITIES    OF    TUBEECULOUS    DISEASES    TO    CANCEE.       721 

ized  or  absorbed.  Calcareous  concretions,  that  had  their  origin  in  tu- 
berculous  matter,  may  be  found  imbedded  in  or*upon  bone,  inclosed  in 
indurated  osseous  or  periosteal  tissue  ;  but  they  are,  I  believe,  ex- 
tremely rare.  Healing  of  tuberculous  cavities  and  ulcers  in  bone  is 
less  rare.  No  new  bone  may  be  formed ;  but  the  membrane  lining  a 
cavity  may  become  thick  and  tough  ;  its  contents  may  become  denser 
and  drier  ;  and  the  bone  for  a  short  distance  around  it  may  be  hard- 
ened and  solidified ;  and  all  the  morbid  process  may  cease.  Or,  the 
surface  of  an  ulcer  may  gradually  heal ;  compact  hard  bone  forming 
on  it,  and  combining  with  the  thickened  and  scarred  periosteum  and 
superjacent  tissues.  Or,  lastly,  though  rarely  after  tuberculous  disease, 
when  t>wo  ulcerated  surfaces  of  bone  come  into  contact,  they  may  unite 
and  coalesce ;  as  in  the  anchylosis  which  may  ensue  after  tuberculous 
ulceration  of  the  articular  portions  of  bones,  or  between  vertebrae,  in 
some  of  the  cases  of  tuberculous  disease  of  the  spine,  or  among  the 
bones  of  the  carpus  or  tarsus.  In  all  these  instances,  it  may  be  gene- 
rally observed  that,  as  inflammation  of  the  bone  preceded  and  bordered 
the  tuberculous  deposits  and  ulcers,  so,  when  healing  ensues,  the  bone 
adjacent  to  the  scar  or  cavity  is  hardened,  pale  yellowish  white,  less 
vascular  than  in  health,  and  made  heavier  and  more  nearly  solid  by  the 
thickening  of  its  cancelli. 

The  instances  of  tuberculous  disease  which  have  now  been  described 
may  suffice,  I  hope,  for  all  that  I  can  have  in  view ;  namely,  the  illus- 
tration of  the  general  characters  of  the  disease  and  the  principal  facts 
on  which  to  form  an  opinion  concerning  its  nature  and  affinities. 

On  first  thought,  there  may  seem  little  right  to  assume  such  a  rela- 
tion between  tubercles  and  tumors  as  is  implied  by  their  inclusion  in 
this  volume  :  yet  the  features  of  resemblance  are  not  few  or  inconsi- 
derable. The  question,  broadly  stated,  is,  whether  tuberculous  diseases 
have  nearest  likeness  to  inflammations,  or  to  cancers.*  It  is  a  very 
difficult  one  to  answer,  for  there  are  apparently  good  arguments  on 
both  sides.  On  the  whole,  I  am  disposed  to  think  that  the  really  tuber- 
culous diseases  are  more,  and  in  more  significant  things,  like  the  can- 
cerous than  they  are  like  any  others.  Therefore,  I  have  spoken  of 
them  here,  and  have  arranged  the  illustrations  of  them  in  a  correspond- 
ing place  in  the  College  Museum.  But  I  will  now  state  both  sides  of 
the  question. 

*  The  observations  of  Virchow  and  Schroeder  van  der  Kolk,  respecting  the  formation  of 
tuberculous  matter  in  epithelial  cells  and  other  natural  tissue-elements,  are  not  opposed  to 
this  mode  of  stating  the  question.  It  may  be  said  that  there  are  many  points  of  resem- 
blance betvi^een  tuberculous  diseases  and  the  degenerations  of  parts  ;  but  it  would  be  a  very 
far,  and,  I  think,  a  very  injudicious,  extension  of  our  ideas  of  degenerations,  to  include  the 
process  for  the  formation  of  tubercles  among  them.  The  differences  between  the  tubercu- 
lous disease  and  all  the  natural  processes  of  merely  defective  nutrition,  separate  it  widely 
from  all  degenerations  properly  so  called.  The  tuberculous  material  naturally  degenerates; 
but  its  production  cannot  be  reasonably  called  a  process  of  degeneration  in  any  normal  parr 


722  AFFINITIES    OF    TUBERCULOUS    DISEASES. 

I.  The  likeness  between  the  tuberculous  diseases  and  the  inflamma- 
tions with  lymph  products  that  are  least  capable  of  development,  seems 
to  be  shown  in  these  things  : 

(1.)  The  likeness  between  tubercle  and  such  lymph  products  is  often 
too  great  for  diagnosis  :  they  have  been,  and  are,  often  confounded  ;* 
and  the  withered  and  degenerated  nuclei  and  other  particles  of  which 
tubercles  are  chiefly  composed  are,  at .  least,  as  much  like  those  of 
degenerate  inflammatory  lymph  as  they  are  like  any  other  morbid 
products. 

(2.)  Inflammation,  indicated  by  all  its  signs,  is  a  common  but  not 
necessary  precedent  and  attendant  of  tuberculous  deposit.  It  evidently 
exists  in  nearly  all  cases  of  the  acute,  and  in  many  of  the  chronic,  tuber- 
culous afi"ections  of  the  glands,  lungs,  and  other  parts ;  and  inflamma- 
tory lymph  capable  of  complete  development  is  sometimes  mingled  with 
tuberculous  matter. 

(3.)  The  degenerations  of  tuberculous  matter  are,  in  all  essential 
points,  parallel  with  those  of  inflammatory  lymph ;  and  so  are  the  pro- 
cesses preceding  and  following  the  discharge  of  the  liquefied  product. 

(4.)  The  same  constitutional  peculiarities  (so  far  as  they  can  be  ob- 
served) precede  and  attend  the  tuberculous  diseases  and  the  so-called 
scrofulous  inflammations  which  are  not  productive  of  tuberculous  de- 
posits. 

Whether,  therefore,  w^e  consider  the  local  or  the  constitutional  parts 
of  the  process,  there  may  seem  no  boundary-line,  no  mark  indicating 
essential  dissimilarity  between  the  tuberculous  diseases  and  the  inflam- 
mations producing  lymph  nearly  incapable  of  development.  The  con- 
clusion, therefore,  might  be,  that  the  local  disease  is  a  specific  inflam- 
mation, dependent  on  a  peculiar  diathesis  or  constitution  of  the  blood, 
and  to  be  studied  according  to  its  analogies  with  gout,  rheumatism, 
syphilis,  and  the  constitutional  afiections  that  are  manifested  by  local 
inflammations. 

On  the  other  side,  it  may  be  said — (1)  that  the  likeness  between 
tubercle  and  degenerated  lymph  is  only  that  into  which  a  large  number 
of  both  normal  and  morbid  products  merge  in  similar  degenerations ; 

*  The  doctrine,  now  so  rapidly  gaining  ground,  that  the  corpuscles  of  inflammatory 
lymph,  and  those  of  tubercle,  take  their  rise  from  the  pre-existing  elements  of  the  textures, 
and  not  in  an  exudation  poured  out  from  the  blood  (pages  266  and  710,  notes),  furnishes  us 
with  a  not  improbable  explanation  of  the  close  resemblances  which  so  often  characterize 
these  corpuscles,  and  which  in  so  many  instances  obscure  their  diagnosis.  For  the  textural 
changes  which  precede,  and,  up  to  a  certain  stage,  accompany  their  formation,  are,  so  far  as 
our  present  means  of  observation  enable  us  to  determine,  the  same.  Then,  after  a  certain 
stage,  in  all  well-marked  cases  the  resemblance  between  the  processes  ceases,  and  the  cor- 
puscles assume  their  specific  characters.  But  if  it  should  so  happen  that  the  influences 
which  might  tend  to  stamp  them  with  specific  forms  are  but  slight,  if  the  type  of  the  dis- 
ease be  but  faintly  indicated,  so  that  their  development  is  impeded,  then  no  true  differ- 
entiation occurs,  and  the  diagnosis  necessarily  becomes  difficult.  In  such  cases  corpuscles 
may  be  found,  of  which  it  may  be  hard  to  say  whether  they  should  be  regarded  as  belong- 
ing to  inflammatory  lymph  or  to  tubercle. 


AFFINITIES    OF    TUBERCULOUS    DISEASES.  723 

(2)  that  the  coincidence  of  inflammation  and  tuberculous  deposit  is  ac- 
cidental and  inconstant,  and  that  the  mingling  of  the  developint/  pro- 
ducts of  the  one,  with  the  degenerating  materia]  of  the  other,  proves 
their  essential  difference ;  (3)  that  the  same  methods  of  degeneration, 
and.of  disposal  of  liquefied  materials  which  are  observed  in  tubercle  and 
aplastic  lymph,  may  be  noticed  in  other  products, — for  instance,  in 
cancerous  and  other  growths  with  ill-developed  structures  ;  and  (4)  that 
the  similarity  of  the  constitutional  states  only  justifies  the  expression, 
that  "scrofulous"  persons  are  peculiarly  liable  to  tuberculous,  as  well 
as  to  inactive  inflammatory,  diseases. 

II.  The  chief  grounds  for  regarding  tubercle  and  cancer  as  diseases 
of  the  same  order  are  the  following  : 

(1.)  Tubercles  sometimes  appear  as  distinct  masses,  like  tumors,  in 
the  brain,  and  in  other  instances  of  so-called  encysted  tubercle.  And 
the  dissimilarity  between  these  and  tumors,  in  that  they  neither  grow 
by  inherent  power,  nor  are  vascular,  is  only  because  their  elementary 
structures  abort,  and  very  early  become  degenerate ;  it  is  only  the  same 
dissimilarity  as  exists  between  a  degenerate,  and  a  growing,  mass  of 
cancer. 

(2.)  The  general  characters  of  malignant  tumors,  as  deduced  from 
cancers  (p.  343),  are  also  observed  in  tuberculous  diseases :  namely,  the 
elementary  tuberculous  structures  are  heterologous ;  they  are  usually 
infiltrated,  and,  at  length,  exclude,  and  occupy  the  place  of,  the  natural 
textures  ;  they  have  a  peculiar  tendency  to  induce  ulceration  after  soft- 
ening ;  the  walls  of  the  ulcer  are  commonly  occupied  by  tuberculous 
deposits  like  those  which  preceded  it,  and,  while  thus  occupied,  have  no 
disposition  to  heal;  the  tuberculous  deposits  apparently  multiply  in  all 
the  same  manners  as  the  cancerous  do  (compare  p.  697,  e.  s.);  and, 
whether  m  their  extension  or  in  their  multiplication,  there  is  scarcely 
an  organ  or  tissue  which  they  may  not  affect,  though,  like  cancers,  the 
primary  tuberculous  diseases  have  their  "seats  of  election,"  and  differ- 
ent seats  at  different  periods  of  life. 

(3.)  The  tuberculous  diathesis,  the  constitutional  state  which  pre- 
cedes the  formation  of  tubercle,  is  scarcely  producible  by  any  external 
agencies,  except  climate  ;  but  it  is  frequently  hereditary  :  and  in  both 
these  respects  it  resembles  the  cancerous,  and  differs  from  the  merely 
debilitated  state  in  which  the  aplastic  inflammations  occur. 

(4.)  The  cancerous  and  the  tuberculous  diathesis  appear  to  be  incom- 
patible and  mutally  exclusive  :  the  production  of  tubercles  is  extremely 
rare,  but  that  of  lowly  organized  inflammatory  products  is  frequent  in 
cancerous  patients.  Such  incompatibility  implies  that  cancer  and  tu- 
bercle are  equally  and  in  the  same  sense,  constitutional  diseases  ;  very 
different,  yet  of  the  same  order  in  pathology. 

(5.)  The  tuberculous  diathesis,  like  the  cancerous,  regularly  increases, 
and  is  attended  with  cachexia,  which  is  often  disproportionate  to  the 
local  disease.     It  is  true  that  tuberculous  disease  frequently  ceases  in 


'''-4  CONCLUSION. 


a  part,  and  allows  its  healing ;  yet,  if  we  look  to  its  enormous  mortality 
as  the  index  of  its  natural  course,  we  must  see  in  it  a  law  of  increase, 
like  that  exemplified  with  fewer  exceptions  in  cancers.  And  such  a 
law  is  not  usually  exemplified  in  the  specific  inflammatory  diseases ;  for 
they  generally  tend  to  subside  with  lapse  of  time. 

If,  now,  I  leave  the  reader  to  consider  for  himself  the  question  that 
may  thus  be  argued,  I  shall  but  fulfil  a  purpose  kept  in  view  in  all  the 
Lectures,— the  purpose,  namely,  of  offering  materials  for  thought  upon 
subjects  of  which  I  have  not  knowledge.  It  will  be  within  the  same 
scope  if  I  suggest  a  contemplation  of  the  seeming  opposition  between 
the  chief  subjects  of  the  earlier  Lectures  and  the  later. 

In  all  the  affections  considered  in  the  earlier,  we  may  trace  purpose 
and  design  for  the  maintenance  or  recovery  of  the  body's  health.  The 
strengthening  against  resistance,  the  reaction  after  injury,  the  turbid 
activity  of  repair,  the  collection  and  removal  of  inflammatory  products, 
the  casting  of  sloughs,  the  discharge  of  morbid  materials  from  the 
blood,— all  these  are  examples  of  the  manifold  good  designs  of  disease  ; 
and  they  evince  such  strength  and  width  of  adaptation  to  the  emergen- 
cies of  life,  that  we  might  think  the  body  was  designed  never  to  suc- 
cumb before  the  due  time  of  its  natural  decay. 

But  in  the  diseases  considered  in  this  Lecture,  and  in  those  on  tu- 
mors, we  trace  no  fulfilment  of  design  for  the  well-being  of  the  body : 
they  seem  all  purposeless  or  hurtful :  and  if  our  thoughts  concerning 
purpose  were  bounded  by  this  life,  or  were  only  lighted  by  the  rays  of 
an  intellectual  hope,  we  could  not  discover  the  signs  of  beneficence  in 
violences  against  nature,  or  in  early  deaths,  such  as  I  have  here  de- 
scribed. But,  in  these  seeming  oppositions,  faith  can  trace  the  Divine 
purposes,  consistent  and  continuous,  stretching  far  beyond  the  horizon 
of  this  life ;  and,  among  the  certainties  of  the  future,  can  see  fulfilled  the 
intention  of  the  discipline  of  sufferings,  that  only  death  might  mitigate. 
And  if  we  cannot  always  tell  what  is  designed,  for  themselves,  in  either 
the  agony  or  the  calm  through  which  we  see  men  pass  from  this  world, 
and  cannot  guess  why,  for  their  own  sakes,  some  are  withdrawn  in  the 
very  sunrise  of  their  life,  and  others  left  to  abide  till  night ;  yet,  al- 
ways, God's  purpose,  for  our  own  good,  may  be  clearly °read  in 'the 
warning,  that  untimely  deaths  should  make  us  timely  wise. 


I  ?sT  D  E  X. 


Abernethy,  Mr.,  on  classification  of  tumors, 
351 ;   on  pancreatic  tumors,  485. 

Abscess,  formation  of,  267-270  j  opening  of, 
282  ;  in  bone,  279. 

Absorption  ;  preceded  by  transformation,  60  ; 
of  bone,  186  ;  of  degenerate  parts,  60  ;  of 
blood,  137;  of  bloodvessels,  281  ;  of  cancer, 
701 ;  of  dead  tissues,  320  ;  of  inflamed  parts, 
279,  288;  of  inflammatory  lymph,  261,  263. 

Actinia,  experiments  on,  126. 

Adenoid  sarcomata,  486. 

Adhesion,  primary,  149  ;  secondary,  152. 

Adhesions,  formation  of,  250. 

Adhesive  inflammation,  149,  235. 

Adipocere,  92. 

Adipose  tissue,  increased  formation  of,  41  : 
and  see  Fat. 

tumor  :  see  Fatty  tumor. 

Affinity,  elective,  in  parts,  62,  93. 

Age,  as  affecting  repair,  123  ;  general  relation 
to  cancer,  678  :  and  see  Cancer. 

Air,  cysts  containing,  359. 

Albuminous  sarcoma,  515. 

Allocation  of  cancers,  &c.,  577,   784. 

Alveolar  cancer  :  see  Colloid. 

Amputation,  healing  after,  152,  173. 

Amyloid  degeneration,  89,  note. 

Anchylosis,  follov?ed  by  atrophy,  109. 

Aneurism  ;  of  bone,  505  ;  by  anastomosis,  495  ; 
effects  of  pressure  by,  79 ;  Hunter's  opera- 
tion for,  46. 

Antlers,  growth  of,  after  castration,  43. 

Antrum,  osseous  growths  of  the,  481;  polypi 
in  the,  403  ;  teeth  in  the,  396. 

Aplastic  lymph,  260,  714,  e.  s. 

Apoplexy,  with  degenerate  cerebral  and  pul- 
monary vessels,  116. 

Arachnoid,  organization  of  blood-clots  in  the, 
136. 

Arcus  senilis,  118. 

Arrests  of  development,  26. 

Arterial  vascular  tumor,  500. 

Arteries,  contraction  of,  196  ;  degeneration  of, 
113  ;  healing  of  injured,  196  ;  obstruction  of, 
inducing  mortification,  45,  311  ;  inducing 
degeneration  in  cancers,  702  ;  ulceration  of, 
in  progress  of  cancer,  610  :  and  see  Blood- 
vessels. 

Artery,  femoral,  traversing  tumors,  454,  563, 
590. 

Ascites,  fibrine  exuded  in,  300. 

Assimilation,  27  ;  of  blood,  34  ;  in  diseased 
parts,  27;  by  cancer,  696. 

Assimilative  force,  64. 

Asteridae,  repair  in,  124. 

Atheromatous  affection  of  arteries,  113. 

Atrophy,  81,  e.  s.  ;  from  pressure,  80  ;  modes 
of,  84;  see  Degeneration;  of  cancerous  parts, 
691;  distinguished  from  inflammation,  298. 


Auditory  passage,  polypi  in,  404. 
Auricle,  cysts  fasciculated  like  an,  368. 
Autogenous  cysts,  354. 


Baly,  Dr.,  on  ulceration,  290. 

Barky  warts,  628. 

Barlow,  Mr.  W.  F.,  on  paralyzed  muscles,  101  ; 
on  fatty  degeneration,  93. 

Bats,  circulation  in  the  wings  of,  213  ;  their 
temperature,  213  ;  rhythmical  contraction  of 
veins,  214. 

Baum,  Prof.,  on  teeth  in  the  antrum,  396  ;  on 
aural  polypi,  404. 

Bell,  John,  on  aneurism  by  anastomosis,  496. 

Bell,  Dr.  Joseph,  on  pulsating  tumor  of  orbit, 
505  ;  on  villous  cancer,  654,  note. 

Bell,  Sir  C,  on  cancerous  cachexia,  553. 

Bennett,  Dr.  J.  H.,  on  fibro-nucleated  tumors, 
517;  on  cancroid  disease,  597;  on  blood  in 
inflamed  parts,  222. 

Billroth,  Dr.,  on  development  of  bloodvessels, 
159  ;  on  cylindroma,  415  ;  on  mucous  polypi, 
403  ;  on  salivary  glandular  tumors,  416,  456. 

Birkett,  Mr.,  on  mammary  cysts,  382  ;  on 
mammary  glandular  tumors,  485. 

Bites,  &c.,  venomous,  331. 

Blastema,  nucleated,  its  development,  142  ;  see 
also  Nucleated  Blastema. 

Bleeding  :  see  Hemorrhage. 

Blisters,  diflerent  fluids  in,  237. 

Blood,  absorption  of  extravasated,  137  ;  accu- 
mulation inducing  growth,  68  ;  assimilation 
by,  34  ;  in  cancerous  persons,  670  ;  initiating 
inflammation,  301  ;  death  of,  in  dead  parts, 
318;  defect  and  disease  of,  inducing  morti- 
fication, 311,  315  ;  effusion  in  inflammation, 
232  ;  effused,  supposed  origin  of  tumors,  348  ; 
extravasated,  in  wounds,  its  disposal,  134, 
137  ;  in  inflammations,  220  ;  influence  on  in- 
flammatory products,  236  ;  in  vessels  of  in- 
flamed parts,  210;  life  of,  34;  maintenance 
of  morbid  state  of,  67;  materials  of,  deter- 
mining formation,  40  ;  morbid  materials  in, 
36  ;  organization  of,  135  ;  in  tied  arteries, 
200  ;  regular  supply  for  nutrition,  45  ;  right 
state  of,  for  nutrition,  34,  e.  s.  ;  clots,  soften- 
ing of,  259;  stagnant  after  injuries,  154; 
transference  of  cancer,  &c.,  by,  699. 

Blood-cells,  length,  Ac,  of  life,  32;  develop- 
ment of,  61  ;  in  inflammation,  221  ;  white, 
on  wounds,  152. 

Blood-scabs,  167. 

Bloodvessels,  absorption  of,  281  ;  adaptation 
to  atrophy,  98  ;  atrophy  of,  112  ;  initiating 
inflammation,  300;  of  cancers,  564,  694:  in- 
closed by  cancers,  563,  590  ;  cancerous  ulcer- 
ation of,  610;  contraction  on  stimulus,  214; 
in  granulations,  162  ;  enlarged  in  growing 


726 


INDEX. 


parts,  67  ;  in  inflamed  parts,  210  ;  formation 
of  new,  159,  e.  s.,  255  ;  obstruction  of:  see 
Arteries  ;  olBce  of,  in  nutrition,  48  ;  relation 
to  organization,  163  ;  growth  of,  in  tumors, 
504  ;  supplying  tumors,  398  ;  in  erectile  tu- 
mors, 499. 
Boils,  sloughs  in,  315. 

Bone,  abscess  in,  279;  absorption  of,  186,  281  ; 
aneurism  of,  505  ;  atrophy  of,  97,  108,  e.  s.  ; 
cancers  of,  530,  538,  666,  646  ;  cancerous 
ulceration  of,  609  ;  cartilaginous  tumors  on 
or  in,  436,  448;  degeneration  of,  108,  e.  s., 
285  ;  fibrous  tumors  on  or  in,  432  ;  granula- 
tions on,  142,  153,  154  ;  hypertrophy  of,  73  ; 
■  inflammation  of,  253  ;  lengthening  of,  76  : 
myeloid  tumors  on  or  in,  462  ;  in  necrosisj 
320  ;  nutrition  of,  48  ;  seats  of  osteoid  can- 
cer, 646  ;  pus  from,  289  ;  serous  cysts  in, 
359,  note ;  softening  and  expansion  of,  277  ; 
tubercle  in,  719  ;  ulceration  of,  290,  720  ; 
under  cancerous  and  other  ulcers,  347  :  for- 
mation of,  in  cartilaginous  tumors.  442J  443; 
in  fatty  tumors,  401  ;  in  fibro-cellular  tumors,' 
413  ;  in  fibrous  tumors,  426  ;  in  inflammatory 
lymph,  252  ;  in  labial  glandular  tumors,  493  ; 
in  myeloid  tumors,  463  ;  in  osseous  tumors, 
473,  483  ;  in  osteoid  and  medullary  cancers 
483.  ^   ' 

Bowman,   Mr.,   on  healing  of  wounds  in  the 

cornea,  307. 
Brain,  adaptation  of  skull  to,  74,  e.  s.  ;  atro- 
phy of,  117;  bloodvessels   of,  in  red  soften- 
ing, 212;  cysts  in,  with  fat,  hair,  &o.,  391; 
degeneration  of  minute  vessels  of,  116  ;  effects 
of  its  diseases  on  the  cord,   118  ;  effects  of 
exercise,  &o.,  28  ;  penetration  by  ulcer,  347  ; 
sloughing  of,  46  ;  softening  of,  116  ;  tubercle 
in  the,  723. 
Brain-like  epithelial  cancers,  602. 
Breast :  cancer  not  affecting  glandular  tumors 
in  the,  491 ;   cancer  of  the,  following  the  ex- 
cision of  glandular  tumors,  491  ;   hard  can- 
cer of  the  :  see   Scirrhous   Cancer  ;  healing 
after  removal    of,    146  ;    induration    of,    in- 
fluenced by  the  mind,   49  ;  irritable  tumor 
of  the,  421  ;  malignant  fibrous  tumor  in  the, 
666;  medullary  cancer  of,  577;  myeloid  tu- 
mor in  the,  470  :  see  also  Mammary  Gland. 
Brodie,  Sir  B.    C,  on  fatty  outgrowths,  396. 
and  tumors,  398  ;  on  mortification,  315,  <fce., 
on  serpent-poison,  331;   on  cancerous  tuber- 
cle, 621. 
Brood-cells  in  cancer,  612. 
Brow  :  cysts  near  the,  390. 
Brown-Sequard,  M.,  on  repair  of  spinal  cord, 

204  ;   on  nervous  system  in  nutrition,  62. 
Bruch,  Dr.,  case  of  cancer,  670  ;  on  multiform- 
ity of  cancer-structures,  437. 
Budd,  Dr.  W.,  on  symmetrical  diseases,  35. 
Bursas,   365  ;  with   endogenous  growths,  374 ; 
under  corns,  67,  79. 


constitutional  and  specific  disease,  668  ;  pre- 
ceding conditions,  669  ;  morbid   material  in 
the   blood,  669  ;   appropriate  part,  669  ;  ne- 
cessity of  their  coincidence,  669;  and  of  con- 
sidering it,  669  ;  cases,   671 ;  nature   of  the 
cancerous  blood,  672  ;  cancerous  particles  in 
it,    673;    chemistry,    673;    incompatibility, 
674  ;  method  of  its  production,  674 ;  by  in- 
heritance,   674  ;  modification   therein,  676  ; 
inoculation,     677 ;    favorable   conditions  of 
sex,   678;  age,   678;  constitutional  degene- 
racy,   679;  climate,    680;  mental    distress, 
680  ;  increase   of  cancerous  diathesis,   681 ; 
suspension,  682  ;  modification,   682  ;  super- 
session, 682.     Apt  locality,    683;  most  and 
least  frequent  seats,    683 ';  allocation,   683  ; 
liability  of  innocent  tumors,   684  ;  whence 
supposed,  685  ;  acquired  aptness,  685  ;  con- 
genital defect,    685;    disease,    686;    injury, 
686  ;  rule  thence  derived,   686. 
Cancer-structures,  question  of  transformation, 
688  ;   construction,    690  ;    infiltration,    690  ; 
changes     in   affected   parts,    691  ;     primary 
cell-forms,  691;   diagnosis,  691;  multiform- 
ity,   692  ;    conformity   with   normal   types, 
692  ;  stroma,  693  ;  bloodvessels,  694  ;  chem- 
istry,   694 ;    life,    695  ;    growth,    696 ;    two 
ministrant  conditions,  696;  localized  cancer, 
697  ;  extension,    697 ;  in   lymphatics,    697  ; 
multiplication,    698  ;   by   contact,    698 ;  on 
continuous  surfaces,  698  ;  in  groups,  699 ;  to 
distant  parts,  699  ;  by  increasing  diathesis, 
699  ;  by  transference  in  blood,  700  ;  degene- 
rations, 701  ;  diseases,  702  ;  softening,  703  ; 
ulceration,  703;  constitutional  efi"ects,   704; 
primary  and  secondary  cachexia,  704  ;  efi'eets 
of  removal,  705  ;  nosology,  705  ;  likeness  of 
tubercle  to,  723. 
Cancerous  growths  in  cysts,  388;    disease   in 
erectile  tumors,  508  ;   and  cartilaginous  tu- 
mors mixed,  459  ;  following  the  excision  of 
mammary  glandular  tumors,  491. 

parents  :  tumors  in  the  children  of, 

491. 
Cancroid,  597. 

ulcer,  620  ;   of  the  face,  536. 


Cachexia  in  cancer,  704. 

Calcareous  deposits  in  fibrous  tumors,  428. 

Calcareous  degeneration,  84  ;  of  bloodvessels, 
113  ;  of  lymph,  262,  264;  of  cancer,  701- 
of  tubercle,  711,  721.  ' 

Callus  :  see  Repair  of  Fractures. 

Cancellous  osseous  tumors,  473. 

Ca,ncer  :  general  pathology  (for  special  patho- 
logy, see  the  specific  names,  Scirrhous,  &c.) 
Origin  of  cancer-cells  from  pre-existing  tis- 
sue elements,   689,   note ;   hypothesis,    668  • 


Canton,  Mr.,  on  the  arcus  senilis,  lis! 

Capillary  vascular  tumors,  498. 

Capsules,  laminated,   613  ;    investing  tumors. 

Carcinoma  fasciculatum  sen  hyalinum,  638; 
fibrosum,  530,  640;  reticulare,  519,  528: 
see  Cancer. 

Carpenter,  Dr.,  on  the  individual  life  of  parts, 
29,  note  ;   on  vital  and  physical  forces,  62. 

Carter,  Dr.,  on  starch  in  the  tissues,  90. 

Cartilage,  repair  of,  189;  inflammation  of, 
286  ;  increase  in  inflammation,  254 ;  ulcera- 
tion of,  286,  293  ;  in  fibro-cellular  tumors, 

Cartilaginous  tumors  :  general  seats,  436 ;  on 
or  in  bones,  436  ;  construction,  436  ;  texture, 
436;  microscopical  structure,  437  ;  of  basis' 
438  ;  of  cells,  439  ;  of  nuclei,  440  ;  growth' 
443  ;  size,  443  ;  ossification,  443  ;  degenera- 
tion or  defect,  445  ;  softening,  445  ;  cysts, 
446  ;  case  of  extreme  softness,  446  ;  slough- 
ing and  suppuration,  448.  Of  the  long  bones, 
448  ;  of  the  jaws,  450  ;  of  the  skull  and  ver- 
tebras, 451  ;  of  the  hands,  451  ;  by  the  pa- 
rotid and  submaxillary  glands,  454.  General 
nature,  467 ;  recurrence,  467 ;  extension 
along  lymphatics,  458  ;  hereditary,  459  ; 
conjunction  with  cancer,  459  ;  and  with  other 
tumors,  461. 


INDEX. 


727 


Castration,  effects  of,  on  antlers,  &e.,  43. 
Catalytic  action  of  discharges,  292. 
Cauliflower  excrescence  of  uterus,  619. 
Cavernous  tumors,  496,  504. 
Cavities,  tuberculous,  712,  717,  719. 
Cellulose,  presence  probable  of,  in  tissues,  90. 
Centres  of  ossification,  hypertrophy  at,  74. 
Cerebriform  cancer  :  see  Medullary  Cancer. 
Chancre,  lymph  in,  251. 
Channelling  of  bloodvessels,  162. 
Cheesy  metamorphosis,  714. 
Chemical   composition  ;    relation   to  vital  ac- 
tivity, 158. 

changes  in  granulations,  158. 

Chimney-sweep's  cancer,  629  ;  and  see  Epithe- 
lial Cancer. 
Cholesterine  in  cysts,  362,  394. 
Cholesteatoma,  393. 
Chondroma,  435,  note. 
Chorion,  cystic  disease  of,  377. 
Choroid  plexus,  cystic  disease  of,  356. 
Chronic  mammary  tumor,  485. 
Cicatrices  :  see  Scars.     Cancer  of,  623. 
Ciliated  epithelium  in  cysts,  355,  note. 
Clarke  Lookhart,  Mr.,  on   atrophy  of  nerve- 
cells,    98  ;    on   connective    tissue    in   spinal 
cord,  118. 
Climate  ;  relation  to  cancer,  680. 
Clitoris,    cancerous   cysts   in   the,"  389  ;    out- 
growth of,  405. 
Clivus,  exostosis  of,  474. 
Clot :  see  Blood-Clot. 
Coagulable  lymph,  233  :  see  Lymph. 
Cold,  producing  mortification,  313. 
Colloid  cancer  ;  primary  seats  of,  658  ;  general 
characters,    668  ;     manner    and    extent    of 
growth,  659  ;  mingled,  660  ;    minute  struc- 
ture, 660  ;  analysis,  661  ;  relations  to  other 
cancers,   663  ;    general  relations  of  cysts  to 
cancers,  663  ;  general  history  of,  665  ;  like- 
ness to  cartilaginous  tumors,  446. 

cysts,  369. 

Collonema,  402,  note. 
Common  disease,  322. 

Complemental   nutrition,    39,    e.    s.  ;    in    dis- 
ease, 40. 
Compound  cysts,  373. 
Concurrent  development  of  organs,  43. 
Conditions  of  nutrition  :  see  Nutrition. 
Condyloma,  628,  685. 

Congenital  defects  ;  liability  to  disease,  643. 
—  excesses  ;  contrast  with  tumors,  341, 


Coote,  Mr.,  on  vascular  tumors,  501,  507. 

Cord,  spinal,  consequences  of  injury,  51  ;  atro- 
phy of,  117. 

Cornea,  fatty  degeneration  of,  118 ;  effects  on 
inflammation  of,  118;  ulceration  of,  50. 

Corns,  79  ;  bursa  under,  67. 

Corps  fibreux,  422. 

innomine,  371. 

Corpuscular  lymph,  234  :  see  Lymph. 

Corrosive  properties  of  discharges,  291. 

Cowperian  cysts,  366. 

Cranium  :  see  Skull. 

Croupous  lymph,  236,  708,  &c. 

Crystals,  repair  of,  121. 

Curling,  Mr.,  on  atrophy  of  bone,  97;  on  fibro- 
cystic disease  of  the  testicle,  427  :  on  scrotal 
cancer,  600,  635. 

Cutaneous  outgrowths,  405. 

proliferous  cysts,  389  ;  with  perfect 


note. 


-  hypertrophy,  69. 


Congestion,  active,  215,  e.  s.  ;  mechanical,  re- 
lation to  inflammation,  300. 

Conglomerate  tumor,  454,  note. 

Conical  clot,  200. 

Conjunctiva,  inflamed  after  stimulus  of  retina, 
225,  304. 

Connective-tissue  corpuscles;  their  probable 
use  in  nutrition,  48  ;  development  in  new- 
formed  skin,  205. 

Connective  tissue  ;  development  of,  144,  note  ; 
mucous  form  of,  402  ;  structure  of,  144, 
note  ;  tumor  of,  402. 

Constitutional  disease,  324,  e.  s.  :  see  Specific 
Diseases  ;  become  local,  697  ;  in  cancer,  669- 
704. 

Contraction  of  organized  inflammatory  pro- 
ducts, 252. 

Cooke,  Dr.,  case  of  recurring  mammary  pro- 
liferous cysts,  387. 

Cooper,  Sir  A.  P.,  on  chronic  mammary  tumors, 
485  ;  on  irritable  tumors  of  the  breast,  421. 


skin,  390  ;  in  the  ovaries,  390  ;  in  the  sub- 
cutaneous tissue,  390  ;  in  various  parts,  391. 
Cuticle,  life  of,  31  ;  thickening  of,  79  ;   devel- 
opment of  new,  205  ;  formed  on  granulations, 
156  ;   separating  over  abscess,  284. 
Cuticular  cysts,  391. 
Cylindroma,  415,  note. 

Cysts  or  cystic  tumors,  353  ;  primary  and  se- 
condary, 354;  mode  of  origin,  354;  general 
structure  of,  355 ;  modes  of  development, 
355  ;  their  various  contents,  357 ;  endoge- 
nous formation  of,  375  ;  with  endogenous 
cancerous  growths,  389 ;  exogenous  forma- 
tion of,  376  ;  with  cholesterine,  362  ;  colloid, 
369  ;  complex  ovarian,  375  ;  compound  or 
proliferous,  373  ;  connected  with  Cowper's 
glands,  366  ;  with  organ  of  Giraldes,  371  ; 
with  organ  of  RosenmUUer,  374  ;  cutaneous 
proliferous,  389 ;  gaseous,  359 ;  glandular 
proliferous,  379  ;  mammary  proliferous,  380  : 
Meibomian,  390  ;  mucous,  366  ;  containing 
oily  or  fatty  matter,  369  ;  proliferous  in  the 
thigh  and  other  parts,  384,  385  ;  proliferous 
recurring,  386  ;  sanguineous,  367;  sebaceous, 
epidermal,  or  cuticular,  391 ;  containing 
semen  or  other  secreted  fluids,  .370  ;  serous, 
359  ;  simple  or  barren,  enumeration  of,  353  ; 
synovial,  365  ;  containing  teeth,  395  ;  with 
cancer  in  the  breast,  364  ;  with  cancers  of 
glands,  580  ;  with  epithelial  cancers,  613  ; 
general  relation  to  cancers,  663  ;  in  cartila- 
ginous tumors,  446  ;  in  fatty  tumors,  401  ; 
in  fibrous  tumors,  426  ;  in  myeloid  tumors, 
463;  in  vascular  tumors  or  nsevi,  361,  507. 
Cystic  Cancer  :  see  Colloid. 
Cystoid  growths,  373. 
Cysto-careinoma,  389,  note. 
sarcoma,  373,  389,  488. 


D. 

Dalyell,  Sir  J.  G.,  experiments  on  Hydra  Tu- 
bularia,  &c.,  126,  e.  s. 

Dead  parts,  separation  of,  59. 

Death,  and  degeneration,  distinguished,  59, 
309  ;  natural,  of  parts,  27. 

Decay,  natural,  of  parts,  27  :  see  Degeneration, 
81. 

Degeneration  ;  general  meaning  of,  82  ;  natural 
occurrence  in  old  age,  82  ;  natural  ^ssue  of 
life,  82  ;  design  of  degenerations,  83  ;  their 
importance  in  pathology,  83  :  methods  of,  84; 
amyloid,  89,  note  :  withering,  84  ;  fatty,  84  ; 
calcareous,  84;  pigmental,  85  ;  thickening  of 
primary  membranes,  86  ;  combinations,  86  ; 


728 


INDEX. 


their  occurrence  before  old  age,  86  ;  distinc- 
tion from  diseases,  bQ  ;  general  diagnosis, 
87 ;  relations  with  development,  88 ;  and 
with  diseases,  88  ;  liquefactive,  89  ;  condi- 
tions of,  96;  spontaneous  atrophy  or  degene- 
ration, 98;  contrast,  with  hj-pertrophy,  96. 
—    and  death    distinguished,    69,   309 ; 


mixed  with  morbid  processes,  33 ;  of  the 
fangs  of  teeth,  31  ;  in  inflamed  parts,  276- 
288  ;  of  lymph,  258,  274,  714  ;  of  cancer- 
cells,  527,  588,  611,  643;  of  tubercle,  711; 
of  cancers,  701. 

Dendritic  vegetation,  575,  655. 

Dentigerous  cysts,  395. 

Deterioration  of  parts,  sources  of,  27. 

Determination  of  blood,  215,  e.  s. 

Development,  meaning  of,  26,  246  ;  separate 
from  growth,  26  ;  arrests  of,  26  ;  determina- 
tion of  the  order  of,  41  ;  as  part  of  the  for- 
mative process,  60 ;  in  hypertrophy,  67 ; 
consumption  of  force  in,  122  ;  checked  se- 
parately from  growth,  123;  arrest  or  error 
of,  in  granulations,  157;  congenital  excess 
of,  contrast  with  tumors,  341,  note. 

Diseased  parts,  assimilation  in,  56. 

Diseases  occurring  only  once,  56. 

Diseases  of  cancers,  702;  of  granulations,  157; 
of  organized  lymph,  274. 

Dittrich,  Prof.,  on  pulmonary  apoplexy,  116. 

Dropsies,  mechanical,  232 ;  fibrinous,  230,  240, 
&o. 

Duration  of  life  in  parts,  31. 

Dysentery,  ulcers  in,  290. 


E. 


Ear,  vascular  tumor  of  the,  500  ;  fibrous  tu- 
mors in  the  lobules  of  the,  434. 

Eburnation  of  bone,  280. 

Ecchondrosis  prolifera,  474,  note. 

Ektasie,  cavernous,  603,  note. 

Elastic  tissue  in  adhesions,  252;  in  fibrous  tu- 
mors, 426. 

Election,  seats  of,  37. 

Elective  affinity  in  nutrition,  61-63. 

Elephantiasis  scroti,  405. 

Encephaloid  :  see  Medullary  Cancer. 

Enchondroma,  435,  e.  s.  :  see  Cartilaginous 
Tumor. 

Endogenous  cells,  in  cancer,  612. 

cysts,  376  :   see  Cysts. 

Epidermal  cysts,  391-395. 

Epidermis,  growth  of,  65. 

Epithelial  cancer ;  primary  seats,  596  ;  second- 
ary, 596  ;  superficial  form,  598  ;  warty  and 
other  external  characters,  598 ;  distinction 
from  common  warty  growths,  601,  630  ;  in- 
terior structure,  602;  peculiar  soft  material, 
602  ;  papillary  and  deep-set  portions,  603  ; 
infiltrated  cancer-structures,  604 ;  stroma, 
605;  deep-seated  form,  Qi)b  ;  eases,  606;  ul- 
ceration, 608  ;  microscopic  structures,  610  ; 
their  arrangement,  610  ;  varieties,  612  ;  me- 
lanotic, 616  ;  cylindriform,  615  ;  intermedi- 
ate, 616.  hi  lymphatic  glands,  616;  pri- 
mary, 617;  lungs,  618;  heart,  619;  uterus 
and  vagina,  619  ;  diagnosis  from  other  can- 
cers and  from  rodent  ulcers,  621 ;  cancer  of 
cicatrices,  623.  Pathology  :  influence  of  sex, 
624  ;  age,  625  ;  hereditary  disposition,  626  ; 
injury  or  disease,  627;  warts,  628;  cancer; 
structures  new  formed  in  them,  629  ;  general 
health,  631 ;  growth,  631 ;  ulceration,  631  ; 
pain  and  cachexia,  632  ;  multiplication,  632  ; 


variations  according  to  seat,  634  ;  duration 
of  life,  634 ;  rules  for  operations,  635  ;  in 
cases  of  recurrence,  636  ;  relations  to  other 
cancers,  637. 

Epithelioma,  697. 

Epithelium,  on  adhesions,  &c.,  252. 

Epulis,  433,  466. 

Erectile  tumors,  495,  675. 

Erysipelas,  suppuration  in,  270. 

Ethmoid  bone,  with  cartilaginous  growth,  451. 

Excoriation  in  inflammation,  289. 

Excretion  office  of  each  part,  39. 

Excretions,  mutual,  between  organs,  44. 

Exercise,  effects  of,  in  tissues,  27 ;  inducing 
growth,  68  ;   atrophy  in  defective,  96. 

Exogenous  cysts,  376. 

Exostosis,  473  ;  foliated  or  periosteal,  646  ; 
spongy  or  fungous,  567. 

Exudations,  inflammatory,  229,  233. 

Eye,  acute  cancer  of  the,  584  ;  medullary  can- 
cer of,  685,  587,  588 ;  melanoid  cancer  of, 
641. 

Eyelash,  life  of  an,  30. 


Face,  growths  on  the  bones  of  the,  480. 

Facial  nerve,  influence  on  nutrition,  63. 

False  membranes,  260,  266,  &c. 

Fat,  formed  in  adhesions,  252  ;  in  the  place  of 
atrophied  muscles,  100. 

Fatty  degeneration,  90  ;  general  characters  of, 
91  ;  wasting  of  nuclei,  91  ;  source  of  the  fatty 
matter,  91  ;  imitative  chemical  changes,  92  ; 
adipocere,  92  ;  relation  to  defective  nutri- 
tion, 93;  as  in  old  age,  93;  two  modes  of 
atrophy  in  old  persons,  93  ;  causes  of  fatty 
degeneration,  94  ;  correspondence  with  those 
of  wasting,  95;  relation  to  general  obesity, 
95  ;  voluntary  muscles,  99  ;  of  the  heart, 
103  ;  of  the  uterus  and  the  smooth-fibred 
muscles,  107;  of  bones,  108  ;  of  bloodvessels, 
112;  nervous  tissues,  116;  cornea,  118; 
lymph,  260,  263,  273  ;  of  inflamed  parts,  286  ; 
of  transplanted  parts,  260. 

matter,  in  degenerate  parts,  60  ;  in  the 

uterus  after  delivery,  108. 

tumors:  outgrowths,  396  ;  in  the  heart, 

396 ;  tumors,  tissue  of,  397 ;  its  arrange- 
ment, 397  ;  capsule,  398  ;  bloodvessels,  398  ; 
multiplicity,  398  ;  seats,  398  ;  shifting,  399  ; 
deep-seated,  400 ;  growth,  400  ;  diseases, 
401  ;  causes,  402  ;  in  emaciated  persons,  340. 

Femur,  lengthening  of,  76  ;  absorption  of  neck, 
281  ;  tumor  detached  from  the,  475  ;  fre- 
quent seat  of  osteoid  cancer,  646. 

Fever,  cancer  withering  in,  674. 

Fibrine  in  lymph,  139;  in  effused  fluids,  230; 
delayed  coagulation,  23]  ;  varieties  of,  in 
inflammatory  exudations,  237 ;  degenera- 
tions of,  269. 

Fibrinous  lymph,  233. 

Fibro-calcareous  tumors,  427. 

cellular  tissue,  development  of,  140,  e.  s. 

and  fibrous  tissues,  formed  from 


lymph,  139,' 260. 

tumors.     Previous   descriptions. 


402  ;     Polypi  :     of  the   nose,  403  ;     antrum, 

403  ;  ear,  404  ;  urinary  bladder,  404  ;  rec- 
tum, 404;  vagina,  406;  lacrymal  sac.  406. 
Cutaneous  outgrowths  :  elephantiasis,  405  ; 
Fibro-cellular  tumors,  general  form,  <fcc.,  406  ; 
texture,  407  ;  microscopic  structure,  407 ; 
chemical  character, 407  ;  containing  cartilage 


INDEX, 


729 


or  bone,  408  ;    degenerate,  408  ;    seats,  409  ;  '  Generalization  of  tumors,  459. 

in  the   scrotum,  409  ;     by  the  vagina,  410  ;     Genital  organs,  relations  of  development  of,  42 

in  the  limbs,  413  ;  in  the  testicle,  &c.,  413  ;  j  Gerlach,  Dr.,  on  osteoid  cancer,  649  ;    on    vil 

general  history,  growth,  &c.,  414.  I      lous  cancer,  656. 

Fibro-cystic  tumors,  426  ;  with  cartilage,  461.  j  Giraldes,  organ  of,  371. 
Fibroid  tumors,  recurring,  509,  e.  s.  [  Glands,  products  of  inflamed,  241. 

Fibro-nueleated   tumors:    general    characters    Gland-cells,  length  of  life. 


and  cases,  517. 

plastic  tumors,  462. 


Fibrous  cancer.  665 

tissue,  developed  from  lymph,  250  ;  os- 
sification of,  in  bony  tumors,  479  ;  fibrous 
tumors  in  or  near,  431  ;  in  cancer,   524-530. 

tumors.     Polypi :    of  the  uterus,  422  ; 

of  the  pharynx,  422.  Tumors,  general  shape, 
423 ;  capsule,  423  ;  texture,  423  ;  plan  of 
fibres,  424;  vascularity,  424  ;  microscopic 
structure,  425  ;  muscular  and  other  mixed 
tissues,  425  ;  cysts,  426  ;  calcareous  deposits, 
427  ;  fatty  degeneration  of,  429,  note  ;  soft- 
ening, 429  ;  seats,  429.  Subcutaneous,  430  ; 
protruding,  431 ;  near  fibrous  tissues,  431  ; 
of  thejaws,  432  ;  in  the  lobules  of  the  ears, 
4.34  ;  multiplicity,  434  ;  growth,  435  ;  gene- 
ral nature,  435  ;  malignant,  665  ;  of  the 
breast,  485. 
Fibula,  acute  cancer  of  the,  584;  cartilaginous 

tumor  in  the,  449. 
First  intention,  union  by,  145,  149. 
Forster,  Prof.,  on  aural  and  other  polypi,  404, 
note ;    on   myoma,    426,     note ;  on   salivary 
glandular  tumors,  456,  note. 
Food,  effects  of,  in  the  formation  of  tissues,  41. 
Foot,  atrophy  of,  81  ;  cartilaginous  tumor,  451  ; 
fibro-cellular  tumor  in  the,  413  ;    fibrous  tu- 
mor in  the,  431. 
Forces,  actuating  the  formative  process,  62. 
Form,  organic,  dependent  on  composition,  63. 
Formative   force,  62  ;    its  method,  63  ;    hypo- 
thesis concerning,  63  ;  illustrated  in  repair, 
121  ;  consumed  in  organizing,  122. 

process  ;  its  modes,  26  ;  its  precision, 

36-63  ;  disposal  of  old  particles.  59  ;  degene- 
ration and  death,  59  ;  instanced  in  teeth,  &c., 
59  :  development  of  new  particles,  60  ;  in- 
fluence of  nuclei,  61  ;  repetition  of  parts,  61  ; 
likeness  to  older  structures,  61 ;  nature  of 
formative  forces,  61  ;  theory  of  assimilation, 
62  ;  its  inapplicability,  62  ;  formative  or 
plastic  force,  62  ;  as  in  development,  63  ;  its 
method,  63  ;  dependence  of  form  on  compo- 
sition, 64;  hypothesis,  63;  see,  also,  Nutri- 
tion. 
Fractures,  share  of  the  blood  in  repairing,  136  ; 
followed  by  partial  atrophy,  97  ;  ununited, 
187;  spontaneous,  in  atrophy,  109  ;  in  mol- 
lities  ossium,  110  ;  in  cancerous  patients,  538; 
see  Repair  of  Fractures. 
Frogley,    Mr.,    cases  of  cartilaginous  tumors, 

443. 
Frog's  web,  experimental  injuries  of,  153,  213, 

Frontal  sinuses,  osseous  tumors  in  the,  476. 
Fungus  hsEsmatodes,  645. 


—  ducts,  involved  in  cancer,  524. 

growths,    intra-cystic,   341,   379,  e.  8.  ; 

outlying,  342. 
Glandular    tumors  :    general    relations,    484  ; 
mammary,  485  ;     usual   seats,  486  ;    shape, 
&c.,  486  ;  construction,  487  ;  structure,  487: 
micro.=copic   structure,   488 ;    growth,    489  ; 
pain,  489  ;   disappearance,  490  ;    large   size, 
490  ;    in  the    male,  490  ;  relation  to  cancer, 
491-2;  in  cancerous  families,  492.     Labial, 
492.    Prostatic,  494.     Thyroid,  494.  Mixed, 
on  the  parotid  and  submaxillary  glands,  454. 
Globes,  epidermiques,  613. 
Gluge,  Prof.,  on  albuminous  sarcoma,  515;  in- 
flammatory globules  of,  263. 
Goodsir,  Mr.,  on  absorption  and  ulceration,  p. 
291,  note;   on    endogenous    development   of 
nuclei  in  cysts,  357,  note;     on  formation  of 
new  bone,  180,  note  ;   on  ulceration  of  carti- 
lage, 286. 
Graafian  vesicles  forming  cysts,  353. 
Granulations,  process  of,  152  ;    and  see  Repair 
by  granulation  ;   ossification  of,  177  ;  eflects 
of  inflammation  and  congestion  on,  248  ;   of 
cancer,  548. 
Granulation  cells,  140;  on  bones,  142. 
Granule-cells  and  masses,  263,  &c. 
Growth,  meaning  of,  26  ;  separate  from  devel- 
opment, 26,  123  ;  its  nature,  64  ;  various  du- 
ration, 64  ;    adapted  to  need,  65  ;    hypertro- 
phy, 65  ;    its  rule,  65  ;     instanced  in  cuticle 
and  muscle,  66  ;    with  development,  66  ;    in 
the  uterus,  &c.,  66  ;  conditions  necessary,  67  : 
conditions   inducing    hypertrophy,    68 ;    in- 
creased exercise,  68  ;  increased  materials  for 
nutrition,  68  ;  increased  blood,  68  ;    morbid 
and  inflammatory  hypertrophies,  69  ;    con- 
sumption of  force  in,  123  ;  see,  also,  Hyper- 
trophy. 
Gulliver,  Mr.,  on  degeneration  of  arteries,  113; 

on  softening  of  clots,  260. 
Gum-cancer:  see  Colloid. 

Gums,  cysts  connected  with  the,  362  ;   fibrous 
tumors  of,  433. 


G. 


Ganglions,  365. 

Gangrene  :   see  Mortification 

ceration,  290. 
Gaseous  cysts,  359. 
Gelatiniform  cancer  :   see  Colloid. 
Gelatinous  polypi,  403. 
sarcoma,  402,  454,  note. 


relation  to  ul- 


Hsematoid  Cancer,  645. 

Hair,   life  and  death  of,   30  ;  change  of  color 

under  nervous  influence,  53  ;  excretion   by, 

40  ;  increased  growth  in  afilux  of  blood,  68  : 

in  cysts,  391,  e.  s. 
Hair-follicles  ;  growth  into  cysts,  392. 
Hall,  Dr.  C.  R.,  on  formation  of  tubercle.  710, 

note. 
Hancock,  Mr.,   on   fatty  degeneration  of  the 

bladder,  107. 
Hands,  cartilaginous  tumors  in  the,  451_. 
Hannover,    Prof.,   on    epithelioma,    597, 

&c. 
Harelip  ;  healing  after  operations,  1 52. 
Harting,  Prof.,  on  growth  of  muscles,  72. 
Hawkins,    Mr.,  on  cancerous   ulcers,  &c.,  621, 

623  :  on  epulis,  433  ;  on  cystic  tumors,  507. 
Healing  :  see  Repair  ;  in  paralysed  limbs,  52  ; 

of  ulcers,  293. 
Heart,  atrophy  and  degeneration  of,  96,  97,  e. 


616, 


47 


730 


INDEX. 


s.  103  ;  cancer  in,  619,  673  ;  fatty  degenera- 
tion of  inflamed,  103,  285 ;  fatty  growths 
in,  396  ;  growth  of,  64;   malformed,  26. 

Helmholtz,  Prof.,  on  changes  in  muscles,  28. 

Hemiplegia,  state  of  muscles  in,  101. 

Hemorrhage,  arrest  of,  197  ;  from  cancers,  689  ; 
from  fibrous  tumors,  65. 

Henle,  Prof.,  theoi-y  of  inflammation,  305. 

Hereditary  transmission  of  properties,  675 ; 
disposition  to  cancer,  674  ;  disease,  trans- 
formation in,  327 ;  cartilaginous  tumors, 
459  ;  cysts,  391 ;  osseous  tumors,  482. 

Hernia,  lymph  in  the  sac  and  intestine,  240  ; 
with  sloughing,  318. 

Herpes,  lymph  of,  234,  265. 

Hewett,  Mr.  Prescott,  on  membranes  formed 
from  blood-clots,  135. 

Hodgkin,  Dr.,  his  account  of  cysts,  374. 

Home,  Sir  E.,  on  vessels  in  lymph,  257. 

Homologous  parts,  similar  diseases  of,  38. 

Homologous  and  heterologous  tumors,  343. 

Horns,  epithelial  cancers  like,  600. 

Humerus,  cartilaginous  tumors  on  the,  44§  j 
osteoid  cancer  of,  653. 

Humphry,  Dr.,  on  hypertrophy  of  muscles,  71  ; 
on  softening  of  fibrous  tumors,  428  ;  on  re- 
moval of  tumors,  394. 

Hunter,  John,  on  effects  of  pressure,  79 ;  On 
hypertrophy  of  muscles,  70,  72  ;  on  incom- 
patible diseases,  674;  on  increased  action  in 
inflammation,  295  ;  on  mollities  ossium,  110  ; 
■operation  for  aneurism,  46  ;  on  subcutaneous 
injuries,  132;  ou  union  by  first  intention, 
145  ;  on  union  of  granulations,  165  ;  removal 
of  large  tumor,  455. 

Huxley,  Mr.,  case  by,  335. 

Hyaline  cylinders,  415,  note. 

Hydatid  mole,  375. 

Hydra,  repair  in,  124. 

Hydrocele-fluid,  230 ;  encysted,  of  the  cord, 
370  ;  with  spermatozoa,  372. 

Hydrocephalus,  hypertrophy  of  skull  in,  73. 

Hydrops  fibrinosus,  230. 

Hygromata,  359. 

Hyperostoses,  473. 

Hypertrophy  :  for  general  history,  see  Growth. 
Of  urinary  bladder,  70  ;  other  involuntary 
muscular  parts,  71 ;  induced  by  obstacles  to 
their  action,  71  ;  growth  of  fibres,  72.  Of 
bone  :  in  the  skull,  73 ;  in  hydrocephalus, 
73  ;  with  shrinking  of  the  brain,  74 ;  es- 
pecially at  the  original  centres  of  ossification, 
74.  Lengthening  of  bones,  76  ;  with  curva- 
ture of  the  tibia,  77 ;  inequality  of  limbs, 
78.  Of  cuticle,  79;  effects  of  pressure,  79; 
from  within  and  from  without,  80  ;  occasional 
and  constant,  80.  Of  thyroid  and  other 
glands,  341  ;  of  mammary  gland,  486  ;  of 
cancerous  parts,  691 ;  contrasted  with  tumors, 
337;  distinguished  from  inflammation,  298  ; 
inflammatory,  241  ;  discontinuous  and  con- 
tinuous, 350. 


Ichor,  292. 

Imbibition,  by  parts  in  nutrition,  47. 
Immediate  union,  healing  by,  134,  146. 
Impairment  of  parts,  sources  of,  27. 
Inaction,    or   incubation,    after    injury,    153, 

327. 
Incompatibility  of  cancer  and   other  diseases, 

674,  723. 
Incorporation   of  materials   of  the   blood,  40, 

329. 


Incrusted  warts,  629. 

Incubation  of  disease,  328,  333,  &g. 

Infiltrations,  general  characters  ,of,  343,  350. 

Inflammation,  phenomena  of :  transitions  to  it 
from  normal  nutrition,  209  ;  altered  supply 
of  blood,  209  ;  enlargement  of  vessels,  210; 
method  of,  210  ;  gorging  with  blood,  221  ; 
increased  redness,  211  ;  appearance  of  new 
vessels,  212  ;  changed  shape  of  vessels,  212  ; 
changed  movement  of  the  blood,  213  ;  ob- 
served in  bats'  wings,  213;  contraction  of 
stimulated  vessels,  214 ;  subsequent  dilata- 
tion, 214;  adapted  movement  of  the  blood, 
215;  effects  of  various  stimuli,  215;  pro- 
ducing determination  of  blood,  215  ;  retar- 
dation of  blood,  216  ;  stagnation,  218  ;  ob- 
servations in  bats'  wings,  218  ;  summary  of 
changes  in  the  blood  and  vessels,  218  ;  non- 
coagulation  of  the  stagnant  blood,  219 ; 
causes  of  the  changed  movement  of  the 
blood,  220.  Changed  composition  of  the 
blood,  220  ;  change  in  its  corpuscles,  221. 
Changed  nervous  force,  224;  "  excitement," 
224 ;  transferred  disturbance  of  the  force, 
225  ;  cases  of  this,  225.  Changed  state  of 
the  inflamed  part,  226.  Recovery,  228. 
Products  of  inflammation  :  Sei  urn,  230  ;  con- 
taining fibrine,  230  ;  delayed  coagulation, 
231 ;  distinction  from  fluid  of  mechanical 
dropsies,  232.  Blood,  232 ;  frequency  in 
pneumonia,  232;  blood-stained  lymph,  232. 
Lymph,  233;  fibrinous,  233  ;  corpuscular, 
234  ;  lymph-corpuscles,  234  ;  their  develop- 
ments, &c.,  235  ;  mixed  lymph,  235  ;  relations 
to  organization,  235  ;  plastic  and  aplastic 
varieties,  235 ;  relations  to  adhesive  and 
suppurative  inflammation,  235.  Influence 
of  the  blood  on  inflammatory  lymph,  236; 
observed  in  the  effects  of  blisters,  237.  In- 
fluence of  the  tissue  inflamed,  239  ;  ex- 
amples and  exceptions,  239.  Influence  of 
the  degree  of  inflammation,  240,  244  ;  mixed 
lymph  and  normal  blastema,  240,  249.  Sum- 
mary of  influences  determining  adhesive  or 
suppurative  inflammation,  242.  Muctis, 
242 ;  mixed  lymph,  243  ;  pigmental  cells, 
244.  Developments  of  lymph,  245;  its  inde- 
pendent life,  245;  and  meaning,  245;  and 
necessary  conditions,  247  ;  cessation  of  in- 
flammatory process,  247  ;  and  of  passive  con- 
gestion, 248  ;  what  determines  the  direction, 
248;  formation  of  adhesions,  &c.,  248;  of 
fibrous  or  connective  tissue,  248  ;  its  con- 
traction, 262 ;  of  adipose  tissue,  252 ;  of 
elastic  tissue,  252  ;  epithelium,  252 ;  bone, 
252 ;  cartilage,  254 ;  bloodvessels,  255  ; 
lymphatics,  256  ;  nerve-fibres,  256  ;  times 
for  development,  256.  Degenerations  of 
lymph,  258 ;  conditions  favoring,  259  ;  zw 
fibrine,  withering,  259 ;  fatty,  259  ;  liquefac- 
tive,  261  ;  resolution,  261  ;  calcareous,  261  ; 
pigmental,  262  ;  in  the.  corpuscles,  withering, 
262  ;  fatty,  263  ;  absorption  of  granular  mat- 
ter, 264;  calcareous,  264;  pigmental,  264. 
Pus  ;  inflammatory  suppuration  ;  origin  of, 
from  pre-existing  tissue  elements,  266,  note  ; 
transformation  of  lymph  into  pus,  264;  re- 
lations of  inflammatory  and  reparative  sup- 
puration, 265;  abscess,  267;  its  formation, 
&c.,  268;  opening,  283;  chronic  abscess, 
270  ;  diffuse  suppuration,  270  ;  superficial 
suppuration,  271  ;  relation  of  pus  to  mucus, 
272  ;  relation  to  abrasion  and  ulceration, 
272  ;  degenerations  of  pus-cells,  273  ;  various 
contents  of  chronic  and  recurrent  abscesses, 


INDEX. 


731 


273.  Degenerations  of  organized  h/mph, 
274;  wasting,  274;  fatty  and  calcareous, 
274  ;  pigmental,  274 ;  diseases,  275  ;  hemor- 
rhages, inflammations,  &c.,  275.  Changes  in 
the  tissues,  inflamed :  all  injurious,  276  ; 
their  double  source,  276 ;  softening,  276 ; 
expansion,  278;  absorption,  279  ;  in  opening 
of  abscesses,  28-3  ;  fatty  and  other  degenera- 
tions, 284  ;  calcareous,  287  ;  penetration  of 
elements,  288.  Ulceration,  288  ;  dependent 
on  inflammation,  289  ;  ejection  of  particles, 
289  ;  solution  of  them,  291 ;  corrosion,  291  ; 
ichor,  292  ;  healing,  293.  Nature  and  causes 
of  inflammation :  necessary  constituents, 
293;  quantity  of  nutrition  in  inflammation, 
295  ;"  increased  action,"  295;  diminished 
formative  force,  295 ;  method  of  nutrition 
in  inflamed  parts,  298.  Causes,  299  ;  in 
changes  of  bloodvessels,  300  ;  in  the  blood, 
301  ;  its  localization,  302  ;  in  disturbed  ner- 
vous force,  304  ;  in  the  state  of  parts,  305. 

Inflammation  leading  to  mortification,  310, 
312  ;  specific,  322,  e.  s.  ;  relation  to  repair, 
207  ;  interfering  with  union,  149  ;  in  cancers, 
702  ;  with  tubercle,  722,  &c. 

Inflammatory  hypertrophy,  69. 

products ;   contrasted  with  tumors, 

338. 

Injury,  inaction  after,  153 ;  engendering  in- 
flammation, 307  ;  killing  parts,  310  ;  making 
apt  for  constitutional  disease,  303,  333  ;  as 
cause  of  tumors,  348,  686. 

Innocent  and  malignant  tumors,  contrast  be- 
tween, 343  ;  fusion  of,  706. 

tumors,  general   characters   of,  347  ; 

occasional  constitutional  origin  of,  348  ;  be- 
coming cancerous,  580,  684  ;  in  members  of 
cancerous  families,  626  ;  cancerous  disposi- 
tion fading  in,  676. 

Inoculable  diseases,  40,  302,  329. 

Inoculation  of  cancer,  677. 

Insects,  repair  in,  128. 

Integuments,  cancer  of:  see  Epithelial  Cancer; 
tubercle  in  the,  717. 

Intermuscular  tissue,  fibro-cellular  tumors  in 
the,  412  ;  cancer  in,  537,  563. 

Intestines,  with  gaseous  cysts,  359. 

Intestinal  canal,  hypertrophy  of,  71  ;  hard 
cancer  of,  538  ;  medullary  cancer  of,  581. 

Intra-cystic  glandular  growths,  379,  e.  s. 

Irritation,  209. 

Ivory-like  osseous  tumors,  476, 


J. 


Jaw,  atrophy  with  anchylosis,  109  ;  cartilagi- 
nous tumors  on  the,  450  ;  cysts  in  front  of 
the,  362;  dentigerous  cysts  in  the,  395; 
fibrous  tumors  on  or  in  the,  432 ;  ivory-like 
tumor  of  the,  478,  480  ;  myeloid  tumors  on 
or  in  the,  466  ;  osseous  tumors  of  the,  in  ani- 
mals, 479. 

Jenner,  Dr.,  on  degeneration,  113  ;  on  calcare- 
ous molecules  in  colloid  cancer,  661. 

Joints,  cartilaginous  growths  in,  436  ;  effects  of 
inflammation  about,  251 ;  efi"ects  of  chronic 
inflammation,  254 ;  false,  188  ;  loose  bodies 
in,  436  ;  loose  bone  in,  80  ;  softening  of  liga- 
ments, 279. 

Jones,  Dr.  Bence,  on  changes  of  materials  ot 
the  brain,  28,  297. 

Wharton,  Mr.,  on  the  circulation  in 

the  bat's  wing,  214  ;  on  the  blood  in  inflam- 


mation, 222  ;  experiments  on  inflammation, 
216,  e.  s. 
Juice  of  cancer,  525,  564,  573. 


K. 


Keloid.  406. 

Kidney,  inflammation  in,  287 ;  cystic  disease 
of,  356  ;  effect  of  destruction  of  one,  40. 

Kirkes,  Dr.,  on  adhesions  of  the  pericardium, 
26 1 ;   on  obstruction  of  cerebral  arteries,  116. 

Kblliker,  Prof.,  on  dilated  small  bloodvessels, 
212  ;  on  the  change  of  hairs,  31 ;  on  degene- 
ration in  the  uterus,  107. 

Kreatine,  in  transformed  muscles,  60. 


L. 


Labial  glandular  tumors.  492. 
Labium,  fatty  tumor  in  the,  399  ;  fibro-cellular 
tumorsin  the,  411 :   outgrowths  of,  405  ;  pro- 
liferous cysts  in  the,  384. 
Lactiferous  ducts,  dilated  into  cysts,  363 ;  in- 
volved in  cancer,  528. 
Laminated,    capsules,    613 ;    cells   in    myeloid 
tumors,  469  ;  in  epithelial  cancers.  613  ;  epi- 
dermal scales  in  cholesteatoma,  393. 
Lanugo,  purpose  of,  39. 
Lardaceous  tumor,  398. 
Larynx,  cysts  in  front  of  the,  361 ;  epithelial 

cancer  of,  696. 
Latency  of  disease,  327-334;  of  cancer,  676. 
Lawrence,    Mr.,    on    determination    of  blood, 
219  ;  on  flbro-cellular  tumors,  402  ;   on  glan- 
dular tumors,  485,  e.  s. 
Lebert,  M.,  on  inflammation,  210,  212,  &c.  ;   on 
lipoma,  396;  on  mammary  glandular  tumors, 
486;  on  fibro-plastic  tumors,  461 ;  on  vessels 
of  cancers,  564  ;  on  cancer  and  cancroid,  597, 
625,  661,  Ac. 
Lepoides,  628. 
Liebig,  Dr.  G.,  on  transformation  in  muscles, 

28 
Life  of  blood,  32. 

individual,  of  parts,  28  ;  length  of,  in  each 

part,  31 ;  independent  in  morbid  products, 
245. 
Ligaments,  softening  of  inflamed.  278. 
Ligature  of  arteries,  effects  of,  198, 
Limbs,  unequal  length  of,  76,  e.  s. 
Line  of  demarcation,  319. 
Lions'  bones,  symmetrically  diseased,  36. 
Lip,  arterial  tumor  on  the,  501 ;  cancer  of,  628  : 
and  see  Epithelial    Cancer;    glandular  tu- 
mors in  the,  492  :  glandular  and  bony  tumor 
in  the,  460  ;  proliferous  cysts  in  the,  .384. 
Lipoma,  396  :  see  Fatty  Tumor ;  arborescens, 

398,  655  ;  colloides,  4*01  ;  mixtum,  398. 
Liquefaction  of  fibrine,  Ac.  261. 
Liquefactive  degeneration,  89  ;  in  cartilaginous 
tumors,  445  ;   in  cancer,  703  ;    in  tubercle, 
711. 
Lister,  Prof.,  influence  of  nerves  in  nutrition, 
62  ;   on  exostosis,  474  ;  on  inflammation,  219, 
e.  s. ;   on  structure  of  veins  and  arteries,  214. 
Liston,  Mr.,  on  spermatozoa  in  cysts,  370. 
Liver,  cancer  of  the,  688. 
Lloyd,  Mr.,  on  spermatozoa  in  cysts,  370. 
Local  disease  in  cancer,  670. 
Lung,  cartilaginous  tumors  in,  436,  458 ;  can- 
cer in,  699;   epithelial  cancer  of,   618;  os- 
teoid cancer  of,  653  ;  tubercle  in  the,  707. 


732 


I  iS^  D  E  X. 


Lymph,  for  repair,  139  ;  in  primary  adhesion, 
149  ;  inflammatory,  233  ;  its  developments, 
139  ;  into  fibrous  or  connective  tissue,  157  : 
see  Inflammation  ;  degeneration  of,  258,  274  ; 
varieties  of,  in  blisters,  237  ;  supposed  origin 
of  tumors,  348. 

Lymphatic  glands,  chronic  inflammation,  262  ; 
tubercle  in,  716  ;  enlargement  before  cancer, 
533;  epithelial  cancer  of,  616;  medullary 
cancer  of,  580  ;  osteoid  cancer  of,  648  ;  scir- 
rhous cancer  of,  533. 

Lymphatics,  in  adhesions,  257  ;  ?  in  granula- 
tions, 164;  cancer  in,  697;  in  cancer,  565; 
extension  of  cartilaginous  growths  in,  458. 

Lymph-space  in  bloodvessels,  211. 


M. 


Macartney,  Dr.,  on  immediate  union,  146 ; 
modelling  process,  168. 

Maclagan,  Dr.,  case  of  recurring  fibroid  tumor, 
516. 

Maintenance,  27  ;   of  diseased  blood,  57. 

Malignant  and  innocent  tumors,  fusion  of,  706. 

tumors  ;  general  characters  of,  343  ; 

fibrous  tumors,  665  ;   myeloid  tumors,  471. 

Malum  senile,  109. 

Mammary  gland :  contracted  and  indurated, 
with  cysts,  364  ;  serous  cysts  in  the,  363. 

Mammary  glandular  tumors,  380,  485  ;  neu- 
ralgic, 421 ;  proliferous  cysts,  380  ;  recurring, 
386. 

Many-nucleated  corpuscles  in  myeloid  tumors, 
464. 

Maxillary  bones  :  see  Jaws. 

Median  nerve,  consequences  of  injury  of,  50. 

Mediastinum,  tumor  in,  containing  teeth,  &c., 
395,  note. 

Medicines,  incorporated  in  tissues,  41,  329. 

Medullary  cancer  :  varieties,  561 ;  general  re- 
lations, 562;  usual  seats,  562;  soft  hind; 
shape,  &c.,  563  ;  relation  and  attachments  of 
lobes,  563  ;  capsule,  563 ;  material,  563 ; 
cancer  juice,  563  ;  varieties,  664  ;  bloodves- 
sels, 564 ;  erectile  and  pulsating,  565  ;  lym- 
phatics, 565  ;  nerves,  566  ;  infilt  rat  ions,  566  ; 
in  bones,  567  ;  with  osteoid  cancer,  567  ;  Jinyt 
kind,  567-  Microscopic  characters,  569 ; 
cells,  669;  varieties  of  nuclei,  669;  of  cells, 
571 ;  of  stroma,  or  intercellular  substance, 
573  ;  affinity  with  erectile  tumors,  675.  In 
the  testicle,  576  ;  eye,  bll ;  breast,  577  ;  sicb- 
cutaneous  tissue.  579  ;  multiplicity,  579 ; 
absorption,  580  ;  lymphatic  glaiuls,  580 ; 
rectum,  581.  Pathology  :  influence  of  sex, 
582  ;  age,  582  ;  hereditary  disposition,  683  ; 
injury  and  disease,  684  ;  temperament,  585; 
multiplicity  and  growth,  585  ;  arrest,  686  ; 
ulceration,  586  ;  degenerations,  588  :  wasting 
and  absorption,  688  ;  bleeding,  589  ;  inflam- 
mation, 689  ;  sloughing,  690  ;  pain,  592  ; 
cachexia,  592  ;  duration  of  life,  593  ;  effect 
of  removal,  593  ;  recurrence,  594  ;  rules  for 
operations,  596. 

Melanoid  cancer ;  general  characters,  639 
microscopic,  639;  general  pathology,  641 
color,  643 ;  connection  with  moles,  643 
multiplicity,  644. 

Melieeris,  362,  note. 

Membranes,  products  of  inflamed,  241,  243, 
25*. 

Memory,  connection  with  nutrition,  58. 

Menstruation,  relation  to  cancer,  643. 

Meryon,  Dr.,  on  atrophy  of  muscles,  98,  note. 


Metamorphosis,  in  disease,  327. 

Mettenheimer,  Dr.,  on  the  cystic  chorion,  378. 

Milk  :  cysts  containing,  363. 

Miller,  Prof.,  on  painful  subcutaneous  tumor, 
417;   on  cartilaginous  tumors  on  hands,  453. 

Mind,  eSects  of  its  exercise,  28  ;  its  influence 
on  nutrition,  49  ;  connection  with  a  changing 
brain,  58  ;  depression  of,  in  relation  to  can- 
cer, 680. 

Mixed  tumors  :  fibro-cellular  and  cartilaginous, 
407  ;  cartilaginous  and  myeloid,  461  ;  cartila- 
ginous and  fibro-eystic,  460  ;  cartilaginous 
and  glandular,  454  ;  cartilaginous  and  can- 
cerous, 459. 

Modelling  process,  168. 

of  united  bones.  186. 


Moles  :  liability  to  cancer,  643. 

Mollities  ossium.  109  ;  its  two  forms,  112,  286  ; 
reference  to  additional  cases  :  see  Addenda. 

MoUuscum  simplex,  405,  note. 

Morbid  materials  in  blood,  identity  of,  37  :  see 
Specific  Diseases. 

Morbid  poisons,  325,  e.  s. :  see  Specific  Diseases. 

structures,  maintenance  in.  56. 

Morgagni,  hydatids  of,  371. 

Mortification  :  distinction  from  degeneration, 
309  ;  causes,  310  ;  direct,  310  ;  relation  to 
inflammation,  310;  indirect,  311;  senile 
gangrene,  312 ;  various  causes,  312  ;  ap- 
pearances of  dying  and  dead  parts,  315 ; 
separation  of  them,  319  ;  phenomena  of  ne- 
crosis in  bone,  320  ;  after  loss  of  blood,  45  ; 
after  obliteration  of  vessels,  46  ;  after  injury 
of  the  spine,  50. 

Motor  nerves,  influence  on  nutrition,  63. 

Mucous  cancroids,  416,  note. 

cysts,   366  ;    Nabothian,   366  ;    Cow- 


perian,  366  ;  their  various  contents,  366. 

membranes,  cancer  of  :  see  Epithelial 

Cancer  ;  villous  cancer  in,  654. 


—  polypi,  402,  403. 

tissue,  402,  416,  456. 


Mucus,  242  ;   diagnosis  from  pus,  272. 

Mliller,  Prof.,  on  cholesteatoma,  393;  on  en- 
chondroma,  436  ;  on  carcinoma  reticulare, 
628  ;  on  osteoid  cancer,  646  ;  on  cysto-sar- 
coma,  373,  389,  488,  &c. 

Multilocular  cysts,  373. 

Multiple  tumors,  347 ;  cartilaginous  tumors, 
459  ;  fatty  tumors,  398  ;  fibrous  tumors,  434  ; 
osseous  growths,  483. 

Multiplication  of  cancers  :  see  Cancer,  general 
pathology. 

Muscles,  growth  of,  66  ;  hypertrophy  of,  70, 
e.  s.  ;  effects  of  action,  28 ;  atrophy  and  de- 
generation of,  99  ;  voluntary,  99  ;  the  heart, 
102  ;  smooth-fibred,  107  ;  materials  derived 
from  their  transformations,  60  ;  healing  of 
divided,  195  ;  inflammation  of,  285  ;  hard 
cancer  in,  536. 

Muscular  tissue  in  fibrous  tumors  of  the  uterus, 
426. 

Myeloid  tumors  :  relation  to  the  fibro-plastic, 
461  ;  affinity  to  natural  bone-textures,  462  ; 
situations,  462  ;  general  shape,  463  ;  texture, 
463  ;  cysts,  463  ;  microscopic  structure,  464  ; 
general  history,  465  ;  cases,  466  ;  recurrence 
and  multiplicity,  470  ;  with  cartilage,  461. 

Myoma,  426. 

Myxomata,  402. 

N. 

Nabothian  cysts,  366. 

Nffivi,  497,  506  ;   pigmentary,  liable  to  cancer. 


INDEX. 


733 


Neck,  serous  cysts  in  the,  360  ;  blood-cysts  in  1 
the,  367  ;  proliferous  cysts  in  the,  385  ;  mye-  | 
loid  tumor  in  the,  471. 
Necrsemia  :  see  Mortification. 
Necrosis,  320  :  and  see  Mortification  ;  of  osse- 
ous growths,  482  ;  preceding  cancer,  627. 
Nerves  :  adaptation  to  atrophy,  99  ;  healing  of 
divided,  201  ;  atrophy  after  division,  117;  in 
granulations,  164  ;  in  adhesions,  2.57  ;  fibrous 
tumors  in,  435;  relation  of  painful  tumors  to, 
419. 
Nerve-cells,  atrophy  of,  98,  note. 

force,  defect  of,  inducing  mortification, 

51,  315  ;  changed  in  inflammation,  224  ;  dis- 
turbance of,  initiating  inflammation,  304. 
Nervous  system  :  effects  of  exercise,  28  ;  influ- 
ence on  nutrition,  48,  e.  s.  ;  on  secretion,  51. 

tissues,  degeneration  of,  116. 

Neuralgia,  with  cancer,  552  ;  with  tumors,  420. 
Neuroglia,  118  :  see  also  Addenda. 
Neuroma,  419,  429. 
Neuro-pathological  theory,  305. 
Newport,  Mr.,  on  repair  in  insects,  128. 
Nipple,  hard  cancer  of  the,  532. 
Noli  me  tangere,  621. 
Non-vascular  parts,  nutrition  of,  48. 
Nose,  cutaneous  outgrowth  of,  405  ;  epithelial 
cancer  on,  607;  sloughing  after  bleeding,  45. 
Nosology  of  cancers,  705.  ,     ,  ^    loe 

Nucleated  blastema,  142  ;  in  blood  clot,  lob  ; 

ossification  of,  178. 
Nuclei:    capacity   for   development,    613;    in 
parts  actively  nourished,  61  ;  of  heart-fibres, 
99  •    changes   of,    in  cells,   141 ;    stellate    or 
branched,  in  cartilage,  440,  447 ;   erring,  as 
origins  of  cysts  and  tumors,  356,  358. 
Nutrition:   nutritive   process,    modes  of,    26; 
conditions  of,  34  ;    right  state  of  the  blood, 
34;   assimilation    of  the   blood,  34;    life  ot 
blood    34  ;   diseases  of  blood,  35  ;  symmetri- 
cal diseases,  36  ;  seats  of  election  of  diseases, 
37;    identity   of  specific  morbid   materials, 
37.     Excretory  office  of  each  part,  39  ;_office 
of  rudimental  organs,  39.     Incorporation  ot 
materials  of  the  blood,  41  ;  determining  the 
formation  of  certain  structures,  41  ;  favoring 
the  order  of  development,  42.     Complemen- 
tal   nutrition,  42  ;    simultaneous  changes  m 
nutrition,   44  ;   commensurate  development, 
44  ;  constitutional  disturbance,  44.     Supply 
of  blood,  45  ;  consequences  of  defect,  45  ;  im- 
bibition by  tissues,  46  ;  office  of  bloodvessels, 
47.     Influence   of  the  nervous  system,  48  ; 
of  the  mind,  50  :  injuries  of  nerves,  30  ;  in- 
constancy  of  efi-ects,  52.     Healthy   state  ot 
the  part  to  be  nourished,  55  ;  assimilation  m 
diseased  parts,  56  ;  and  in  blood  after  diseases, 
56  ;   its  precision,   58  ;  and  in  the  brain,  bJ  : 
see  also.   Formative  Process.  _ 

Nutrition,   altered  conditions  of,  in  inflamma- 
tion, 209  ;   contrast  of  normal  and  inflamma- 
tory, 296. 
Nutritive  repetition,  61. 
Nymphae,  outgrowths  of,  405. 

0. 

O'Ferrall,  Dr  ,  case  of  fibro-cellular  tumor,  410. 
Ogle,  Dr.  John,  on  an  intracranial  cutaneous 

cyst,  391,  note. 
Oily  or  fatty  cysts,  369 

S?brt,T;sts'inTn:afth;,%0  ;  fibro-cellular 
tumor  in  the,  414  ;  medullary  cancer  m,  577  , 
osseous  tumors  growing  into  the,  4/b. 


Organic  affinity,  64. 

form  dependent  on  composition,  63. 

Organization  of  blood  clot,  135. 

Ormerod,  Dr.,  on  fatty  hearts,  107;  on  inflam 

matory  products,  304. 
Osseous  tumors  :  in  soft  parts,  472  ;    of  bones, 
473  ;  chief  kinds,  473  ;  homology,  473  ;  modes 
of  ossification,  474  ;  cancellous,  475  ;  ivory- 
like, 476  ;  of  the  skull,  476  ;  .sloughing,  478  ; 
of  the  lower  jaw,  479  ;   of  the  toes,  479.     Os- 
seous growths  of  the  superior  maxillary  and 
other   bones,   480  ;    of  the  skull  bones,  482. 
Multiple  osseous  growths,  483  ;  symmetrical 
and  hereditary,  483.     Distinctionsof  the  bone 
in  osseous  and  other  tumors,  483  ;  malignant, 
646. 
Ossific  diathesis,  483. 

inflammations,  253. 

Ossification,  in  repair  of  fractures,  178;  of  car- 
tilaginous tumors,  442,  443  ;  of  myeloid  tu- 
mors, 463. 
Osteoid   cancer  :  general    nature,   646  ;    seats, 
646  ;  general  characters,  647  ;   in  lymphatic 
glands,    648  ;    microscopic   characters,    649  ; 
fibrous,  649  :  osseous,  649  ;  affinities  to  osseous 
tumors,   650  ;    and  medullary  cancers,  567, 
650  ;  general  pathology,  651  ;  secondary  dis- 
ease, 651  ;  cases,  652  ;  characters  of  bone  in, 
484. 
Osteo-chondroma,  435,  note. 
Osteomalacia,  111. 
Osteophyte,  253. 
Osteo-sarcoma,  435,  note  ;  483. 
Outgrowths:    general  characters  of,    ^a"  i    cu- 
taneous, 405  ;  fatty,  396  ;  fibrous,  422,  4..3  ; 
osseous,  472  ;  multiple  osseous,  483  ;  ot  blood- 
vessels, 161. 
Ova,  length  of  life,  33.  _ 

Ovary,  cysts  in,  375  ;   their  affinities  with  can- 
cer   388,  660  ;   containing  skin  and  its  pro- 
ducts, 389,  490  ;  with  teeth,  395  ;   hard  can 
cer  of,  540. 
Overgrowth  :  see  Hypertrophy. 
Owen,    Prof.,  on  ossification,    87;  on  tubular 
system  in  tendon,  48. 


P. 

Pachydermatocele,  406. 

Pain,  in  mammary  glandular  tumors,  489  ;  witH 
cancer,  551  ;  nature  of,  in  tumors,  418. 

Painful  subcutaneous  tumors:  general  seats 
and  relations,  416  ;  microscopic  structures, 
417;  pain,  418;  growth,  418;  distinctions 
from  neuromata,  419  ;  neuralgic  pain,  4^U  ; 
pain  in  other  tumors,  421. 

Palate,  absorption  of,  under  pressure,  80. 

Palsy,  wasting,  98.      .  _ 

Pancreas,  cystiform  dilatation  ot,  60i. 

Pancreatic  tumor,  485. 

Pap?"*-    new   formation   of,    205  ;    cancerous, 

fiOl    603    620  :  and  see  Epithelial  Cancer. 
Paralyzed  parts,  nutrition  in,  52  ;  treatment  ot, 

Pirotid,  blood-cysts  on  or  in  the,  368  ;  cartila- 
ginous tumors  on  or  in  the,  464  ;  cysts  over 
the,  361  ;  cancer  in,  587. 

Ppnrlv  tumor,  393,  note. 

Lchincuirted  intr'acystic  and  other  growths, 
379,  note. 

Perforating  ulcers,  311.  ,   r    „    ori 

Pericardium,  absorption  of  lymph  from,  -61. 

Ppriodicitv,  in  disease,  32/,  3.io.  . 

?eriosteum:  its  injury  in  fractures,  176;  im- 


734 


INDEX. 


portanee  of,  in  formation  of  new  bone,  180, 
note  ;  cancer  rising  from,  624  ;  in  medullary 
cancers,  566. 
Peritoneum,  colloid  cancer  of,  659. 
Peritonitis,  lymph  in,  250,  e.  s. 
Perpetuated  morbid  changes,  345. 
Personal  modifications  of  disease,  .335. 
Phalanx  of  the  toe.  osseous  tumor  on  the,  479. 
Pharynx,  fibrous  polypi  in  the,  422. 
Phillips,  Mr.,  on  vascular  tumors,  508. 
Phlebolithes,  in  venous  tumors,  506. 
Phymatoid  substance,  588,  713. 
Phymosis,  effect  on  the  bladder,  72  ;  preceding 

cancer,  628. 
Physalides,  612. 
Physaliphores,  612. 
Pigment  in  melanoid  cancer,  639,  643. 
Pigmental  degeneration,  85  ;  of  small  arteries, 
113,  note;   degeneration  of  lymph,  262,  264, 
274  ;  in  mucus-cells,  244. 
Pigmentary  naevi,  liability  to  cancer,  643. 
Places,  morbid  products  in  certain,  684. 
Plastic  force,  62. 

and  aplastic  lymph,  260. 

Pleurisy,  lymph  in,  247,  249,  e.  s. 
Pleuro-pneumonia,  mixed  lymph  in,  240. 
Pneumonia,  effusion  of  blood  in,  232  ;   lymph 

in,  240. 
Pointing  of  abscesses,  283. 
Poisoned  wounds,  303. 

Poisons,  morbid,   324,  e.  s.  :   see  Specific  Dis- 
eases. 
Polypi,  402  ;  fibrous,  422. 
Porcellaneous  change  in  bone,  280 
Pott's  disease  of  spine,  720. 
Predecessors,  formation  after  plan  of,  120. 
Predisposition,  meaning  of,  676. 
Pressure,  effects  of,  on  nutrition,  80  ;  producing 

sloughs,  312. 
Primary  adhesion,  149. 
Prodromata  of  specific  diseases,  335. 
Progenitors  imitated  in  offspring,  63. 
Proliferous  cysts,  373  ;  in  the  ovaries,  373  ;  with 
broad-based  endogenous  cysts,  375  ;  with  pe- 
dunculated cysts,  376  ;   intermediate  forms, 
376  ;  in  the  cystic  chorion,  377 ;  their  minute 
structure  and  development,  378.     With  glan- 
dular endogenous  growths,  379  ;  in  the  mam- 
mary   gland,    380  ;     method  of    intracystic 
growth.  380  ;  consolidation  and  protrusion  of 
the    growths,    382  ;  general  structure  of  the 
growths,  382  ;  their  minute  glandular  struc- 
ture, 382  ;  their  structure  not  evidently  glan- 
dular, 383.     In  the  lip,  384;  in  the  labium, 
384  ;  in  various  parts,  385.  Recurring  prolife- 
rous cysts  in  the  breast,  386  ;  in  cancers,  .388. 
Prostate     gland,    intracystic     and     detached 

growths  of,  342. 
Prostatic-glandular  tumor,  494. 
Purpose,  in  relation  to  accidents,  120;   in  dis- 
eases, 724. 
Pus,  265  :  see  Inflammation  and  Suppuration  ; 

transference  in  blood,  700. 
Pyogenic  membrane,  269. 


Quain,  Dr.,  on  fatty  hearts,  92,  e.  s. 

Quekett,  Mr.,  on  formation  of  new  vessels,  162; 

on  ossification  in  cartilaginous  tumors,  442  ; 

on  osseous  tumors,  473,  477. 

R. 

Rabbits'  ears,  inflamed,  210. 


Ranula,  probable  varieties  of,  354. 
Recovery  from  inflammation,  process  of,  228. 
Rectum,  hard  cancer  of,  530  ;   polypus  of  the, 

404. 
Recurrent  tumors,  343,  508. 
Recurring  cartilaginous  tumors,   457  ;  fibroid 

tumors,  511,   e.  s.  ;  myeloid  tumor,  471,  510  ; 

proliferous  cysts,  386. 

fibroid  tumors  :  cases,  511. 


Redfern,  Dr.,  on  repair  of  cartilage,  189  ;  on 
inflammation  of  cartilage,  285. 

Reid,  Dr.  John,  on  paralyzed  muscles,  101. 

Relaxing  process  over  an  abscess,  283. 

Removal  of  cancer,  effects  of,  705  ;  partial, 
587-8. 

Repair  and  reproduction  after  injuries,  119  ; 
adaptation  of  parts  for  future  events,  120; 
illustrations  of  the  formative  force,  120.  Re- 
pair of  crystals,  121;  its  degrees  in  animals, 
122  ;  at  different  ages,  123  ;  according  to 
amount  of  development,  123.  Repair  in  as- 
teridse,  actiniae,  and  hydras,  124  ;  in  tubu- 
laria,  127 ;  gradual  recovery  of  perfection, 
127.  Repair  in  insects,  128,  and  lizards,  129; 
in  man  and  other  mammalia,  129  ;  general 
deductions,  130.  Materials  for  repair, 
132  ;  distinction  between  subcutaneous  and 
open  injuries,  132.  Methods  of  repair,  134. 
Organization  of  blood,  134;  its  share  in  re- 
pair, 138.  Lymph,  139  ;  its  usual  develop- 
ments, 140  ;  granulation-cells,  140  ;  on  bones, 
142  ;  nucleated  blastema,  142  ;  developments 
of  fibro-eellular  tissue,  144 ;  from  mixed 
products,  144. 

of  open  wounds,  146  ;    hy  imTnediate 

union,  146.  Dr.  Macartney's  account,  146  ; 
description  of  cases,  146;  and  experiments, 
147  ;  the  best  healing,  148  ;  conditions  ne- 
cessary for  it,  148  ;  by  primary  adkesion,  149. 
Hunter's  account,  149;  examples  of  the  pro- 
cess, 150  ;  its  quickness,  150  ;  by  granulation, 
151 ;  glazing  of  an  open  wound,  162 ;  inaction 
after  injury,  153  ;  granulations  forming,  154; 
afflux  of  blood,  154  ;  comparison  with  inflam- 
mation, 154;  effusion  of  reparative  material, 
155  ;  its  vascularization,  155  ;  minute  struc- 
ture, 156;  without  suppuration,  156;  devel- 
opment, 156  ;  arrest  or  error,  157  ;  and  dis- 
eases, 157 ;  contraction,  173  ;  chemical 
changes,  159  ;  formation  of  new  vessels,  160  ; 
three  modes,  160, — that  by  outgrowth,  161  ; 
by  channelling,  162  ;  general  arrangement 
of  vessels,  162;  structure,  164;  relations  to 
organization,  164  ;  development  of  nerves 
and  lymphatics,  164;  by  secondary  adhesion, 
164;  its  plan,  165;  examples,  166;  condi- 
tions necessary,  166;  by  scabbing,  166;  its 
process  with  blood,  167  ;  with  pus,  167  ;  sup- 
puration and  sears  (see  these  words) . 

fractures,  175  ;  nature  and  extent  of 

injury,  175  ;  extravasation,  176  ;  inflamma- 
tion, 176  ;  period  of  calm,  176;  commence- 
ment of  repair,  177  ;  immediate  union,  177  ; 
reparative  material  or  callus,  177  ;  its  rudi- 
mental  state,  177  ;  ossification  through  fibrous 
tissue,  178  ;  through  cartilage,  178  ;  charac- 
ters of  the  new  bone,  179  ;  position  of  the  re- 
parative material,  180  ;  provisional  or  en- 
sheathing  callus,  180  ;  interior  callus,  181  ; 
intermediate  callus,  182  ;  differences  of  repair 
in  man  and  animals,  184  ;  modelling  after  the 
repair,  185  ;  repair  of  compound  fractures, 
187;  times  of  the  stages  of  the  repair,  187  ; 
failure  of  repair,  187;  false  joints,  &c.,  187. 
Repair  of  cartilage,  189;   of  tendons,  190  ;  dis- 


INDEX. 


735 


advantages  of  open  wounds,  191  ;    effect  of 
dividing  the  sheath  of  connective  tissue,  191 ; 
repair  after  subcutaneous  division,  192  ;  re- 
traction of  upper  portion,  192  ;     extravasa- 
tion,   192  ;   exudation,  192  ;    reparative  ma- 
terial, 193;  its  development,  193;  imperfec- 
tion, 194;    strength  of  the   union,  195.     Of 
muscles,    195.     Of  arteries   and  veins,  196  ; 
with  small  wounds,  196  ;    with  partial    divi- 
sion, 196  ;  with  complete  division,  197  ;  con- 
traction and  retraction,  197  ;   after  ligature, 
198 ;     inflammation   of  the    tied   end,    198 ; 
contraction  of  the  part  above  it,  199;  changes 
in  the  stagnant  blood,  199.     Of  nerves,  201 ; 
cases    of    primary    union,    201  ;     secondary 
union,   203  ;    formation  of  new  fibres,  204 
repair  of  nerve-centres,  204.     Of  skin,  205 
new  formation  of  papillae  and  cuticle,  205 
relation  to  inflammation,  206. 
Repetition,  nutritive,  61. 
Reptiles,  repair  in,  129. 
Resolution  of  inflammation,  261. 
Reticulum  of  cancer,  701. 
Rheumatism,  localization  of,  303. 
Rickets,  112  ;  efi'ect  of  on  tibiae,  77. 
Right  state  of  blood,  34. 
Ringing  effects  of,  41. 
Roberts,  Dr.,  on  wasting  palsy.  98. 
Robin,  M.,  on  vessels  in  erectile  tumors,  499  ; 

on  epithelioma  of  kidney,  596. 
Rodent  ulcer,  621. 

Rokitansky,  Prof.,  on  the  formation  of  cysts, 
35  5  ;  on  dendritic  vegetation  in  villous  can- 
cer, 655  ;  on  degeneration  of  arteries,  113  ;  on 
erectile  cavernous  tumors,  504,  575  ;  on  endo- 
genous cells  in  cancer,  614  ;  on  inflammatory 
products,  236  ;  on  stroma  of  cancer,  &c.,  574  ; 
on  tubercle,  &c.,  708.  _  _ 

RoUeston,  Prof.,  on  complementary  nutrition, 
44 ;   on  appendicular  structures  to  the  testis, 
372 
Rosenmiiller,  organ  of,  374. 
]^dimental  organs,  purpose  of,  39. 


brous   tissue,    530.       Varieties :    acute  and 
chronic,  531  ;     of  the  niyjple  and  skin,  531. 
In  the  lym-phalic  glands,  533  ;    in  the  skin, 
535;    muscles,  b?>^  ■■.     hones,  b'Al ;    intestinal 
ca7uil,  538  ;  mingled  forms.  5.39  ;  fibrous  can- 
cer, 540  ;   in  ovaries,  Ac,  540.     Pathology  : 
influence  of  sex,  442  ;  age,  542  ;  of  menstrua- 
tion, 543  ;    hereditary  disposition,  544  ;    in- 
jury, 545  ;  general  health,  545  ;  first  appear- 
ance, 546  ;  growth,  546  ;     multiple  growths, 
547  ;  ulceration,  547  ;  superficial,  547  :  sub- 
stantial,   548 ;    softening,    549  ;     arrest  and 
healing,  550  :    in  connection   with    phthisis, 
550  ;   shrivelling-,  551  ;  pain,  552  ;  cachexia, 
553  ;  primary  and  secondary,  553  ;   multipli- 
cation, 553  ;    duration,  554  ;    effect  of    age, 
555  ;  efi"ect  of  removal,  557  ;  recurrence,  557  ; 
second   recurrence,    557 ;    rules   concerning 
operations,  559. 
Scrofula,  relation  to  tuberclous  disease,  715. 
Scrofulous  matter,  260,  263,  715. 
Scrotum,    cancer    of:    see  Epithelial   Cancer; 
fatty  tumor  in  the,  399  ;    fibro-cellular   tu- 
mors in  the,  409  ;  hypertrophy  of,  405. 
Sebaceous  and    epidermal  cysts,  391  ;     heredi- 
tary  origin,  391  ;     twofold   formation,  391 ; 
various  characters,  392  ;  of  the  walls  and  of 
the   contents,    392;    ulceration,  394 ;    fatal 
case,    394;    protruded    contents    becoming 
vascular,  395  ;  connected  with  epithelial  can- 
cer, 607. 
Secondary  adhesion,  152. 
cysts,  375,  e 


S. 

Salivary  glandular  tumors,  454,  456. 
Sanguineous  cysts,  367  ;  their  various  contents, 

367  ■  in  the  neck,  368  ;  in  the  parotid  gland,  ^ 

368  i    internally  fasciculated,   368  ;     formed  , 
from  dilated  veins,  369. 

Sap,  effects  of  accumulation,  41. 
Saponification  of  cancer,  688.  I 

Sarcoma,   albuminous,    616  ;    gelatinous,  402, 

454,  note  ;   sero-cystic,  373,  379. 
Scabbing,  healing  by,  166  :  and  see  under  Re- 

Scars^maintenance  and  growth  of,  56  ;  their 
contraction,  173;  improvement  and  gradual 
perfection,  174  ;  loosening,  174  ;  warty  and 
cancerous  growths  on,  623. 

Schroeder  van  der  Kolk,  Prof.,  on  lymphatics 
in  adhesions,  266  ;  in  cancers,  666  ;  on  tu- 
bercle, 709.  ^  .      ^, 

Scirrhous  cancer,  519  ;  usual  form  in  the 
breast,  520  ;  usual  state  of  the  gland,  5.0  , 
hardness,  521  ;  size  and  shape  621  ;  aaue- 
sion  and  retraction  of  tissues,  622  ;  cut  sur- 
face 622;  mixture  of  cancerous  and  natural 
structures,  624  ;  wasting  of  natural  tissues, 

525  ;  cancer  juice  and  stroma    525  ;  mhltia- 
tion   of  cancer-structures,    525;    cells,  &c 

526  ;  degenerate  structures,  527  ;  degenerate 
normal  structures,  527  ;    reticulum,  529  ;  fi- 


Secretion,  influence  of  nervous  force  on,  51. 
Semi-malignant  tumors,  473,  517. 
Seminal   cysts,  370  ;    their  spermatozoa,  .j71 ; 
connections,  371  ;  diversity  of  contents,  372  ; 
degeneracy,  372  ;    spermatozoa  in  the  sac  of 
tunica  vaginalis,  372. 
Senile  gangrene,  313. 
Sequelae  of  diseases,  335. 
Sero-cystic  sarcoma,  373,  note  ;  379. 
Serous  cysts  :  their  contents,  359  ;    seats,  3o9  ; 
in  the  neck,  360  ;    connected  with  the  thy- 
roid gland,  361  ;  transformations  of  vascular 
tumors,  361  ;    with  viscid  contents  and  eho- 
lesterine,  362;  near  the   gums,  362;  in   the 
mammary   gland,  363  ;    dilated  ducts,  363  ; 
autogenous  cysts,  363  ;  confusion  with  mam- 
mary cancer,  364  ;  large  single  cysts,  36o. 
Serpent-venom,  331. 

Sex,  influence  of,  in  cancers  :  see  Cancer,  gene- 
ral pathology.  .    p   .o 
Sexual  characters,  related  development  of,  42. 
Shifting  of  tumors,  399,  514. 
Shortening  of  bones,  78. 

Sibley  Mr.,  on  colloid  cancer,  660,  bbJ  ,  on 
villous  cancer,  654  ;  on  multiple  fibrous  tu- 
mors, 667.  _  „ 
Simon  Mr.,  his  observations  on  cysts,  358  ;  on 
extension  of  cancer,  697  ;  on  morbid  poisons, 
329,  e.  s.  ;  on  scrofula,  716. 
Simpson,  Prof.,  on   congenital  cysts,  360;    on 

reproduction  of  limbs,  123. 
Simultaneous  changes  in  nutrition,  42. 
Skeleton  of  cancers,  574.  .  ,    ,.  ,    ^ 

Skin,  cancer  of:  see  also  Epithelial  Cancer; 
hard  cancer  of  the,  532,  535  ;  intracystic  for- 
mation of,  390  ;  outgrowths  of,  40.>;  repair 
of  wounds  of,  205  ;  reflected,  union  of,  14b  ; 
tubercle  in,  718.  .         , 

Skull,  hvpertrophy  of,  73,  e.  s.  ;  atrophyin  old 
a-e,  108  ;  cartilaginous  tumors  of  the,  4ol , 
granulations  on  the,  154,  165  ;    myeloid  tu- 


736 


INDEX. 


mor  of  the,  467;    osseous  growths  on   the, 
482  :   osseous  tumors  on  or  in,  476. 
Slough  :  see  Mortification. 
Smith,  Dr.,  on  neuroma,  420. 
Snellen,  experiments  on  trigeminal  nerve,  54, 

note. 
Soft  cancer  :  see  Medullary  Cancer. 
Softening,  in  inflammation,  276  ;     over  an  ab- 
scess, 283  ;   of  cartilaginous  tumors,  445  ;   of 
fibrous  tumors,  429;    of  cancers,  70.3  ;  of  tu- 
bercle, 711. 
Solution  of  ulcerating  parts,  290. 
Soot-wart,  629. 

Spallanzani,  on  reproduction  of  parts,  123. 
Specific    diseases  :    distinction,   from  common 
diseases,  322  ;  specific  characters,  323  ;  plan, 
or  construction,  323  ;  causes,  325  ;  local  and 
general    phenomena,   326  ;     disproportionate 
cause  and  effect,  326  :  disproportionate  local 
and  constitutional   states,  326  ;     symmetry, 
(fee,  326;   self-augmentation,   327;  transfor- 
mation, 327  ;  periodicity,  328  ;  theory,  328  ; 
its  application,  330  :  introduction  of  morbid 
materials,  330  ;    their  effect  on  tissues,  330  ; 
example  of  insect-bite,  331  ;     local    aptness 
for  disease,  332  ;  effect  and  changes  in  blood, 
333  ;     increase,    333  ;    transformation,    334  ; 
combination,  335;   separation,  336:  charac- 
teristic formation  of  new  bone  in,  254  ;  mor- 
bid materials,  incorporation  of,  302. 
Sphacelus  :  see  Mortification. 
Spine,  cartilaginous  tumor  on  the,  444,  451. 
Spinal  cord,  atrophy  of,  117  :  effects  of  injury 

of,  51  ;    repair  of  injuries  of,  204. 
Spleen-like  tumors,  463,  note. 
Spurs,  effect  of  transplantation,  69. 
Stagnation  of  blood,  218,  224,  312. 
Stanley,   Mr.,  on   pulsating  tumors,  565  ;    on 
scrofulous  disease  in  bone,  720  ;   on  necrosis, 
321  ;  on  removal  of  exostoses,  473. 
Starch,  presence  in  textures,  89,  90. 
Stasis,  224. 

Steatoma,  396  :  see  Fatty  Tumor. 
Stilling,  Dr.,  on  repair  of  bloodvessels,  199. 
Strangulated  parts,  sloughing,  312,  318. 
Stricture,  cancerous,  of  intesline,  539. 
Stroma  of  cancer,  525,  531,  564,  574,  655,  693. 

See  Scirrhus,   &c. 
Structure  dependent  on  composition,  63. 
Struma,  relation  to  tuberculous  disease,  715. 
Subcutaneous  injuries,  repair  of,  132. 

nsevi,  497,  505. 

tissue,  cysts  in  the,  390  ;  medul- 
lary cancer  of,  579  ;    fibrous  tumors   in  the, 
430  ;  painful  tumors  in  the,  416. 
Submaxillary  gland,  cartilaginous    tumors    on 

the,  454. 
Submucous  tissue,  fibrous  tumors  in  the,  429. 
Suppuration :    in    repair,  169 ;     characters    of 
pus,  169  ;  origin  of  pus,  266;  pus-cells,  169; 
liquor   puris,  172;     relation  of  the    cells  to 
those  of  granulations,  170  ;  their   imperfec- 
tion  or   degeneracy,  171  ;     the  same  of  the 
liquor  puris.  172;  which  may  be  a  liquefied 
blastema,  172;  use  of  pus,  172.     Inflamma- 
tory, 264,  282  :    and  see  Inflammation  ;    of 
cancerous  glands,  580,  618. 
Syme,  Mr.,  on  exostosis,  474;     on  influeoce  of 
periosteum,  179;   on  transition-tumors,  509. 
Symmetrical  diseases,  36  ;  osseous  tumors,  482. 
Sympathetic  nervous  sj'stem,  influence  on  nu- 
trition, 54. 
Synovial  cysts,  365. 
Syphilitic  ulcers,  &c.,  324,  327,  333,  &c. 


Teeth,  life  of,  32  ;   absorption  and  ejection    of 
fangs,  59  ;    induration   of,  280,  note  ;     over- 
growth of,  in  rodents,  80  ;    separation  of,  in 
old  age,  321  ;    in  cysts  and  tumors,  395. 
Teeth-pulps,  effects  of  inflammation  on,  287. 

Telangeiectasis,  495,  499. 
Tendons,  healing  of  divided,  190. 
Testicle,  inflamed  after  stimulus  of  the  urethra, 
225  ;  cartilaginous  tumor  in,  458,  note  ;  car- 
tilaginous and  cancerous  tumors  in  the,  459  ; 
cartilaginous  and  fibro-cystic  tumor  in  the, 
461 ;  fibro-cellular  tumor  in  the,  413  ;  fibro- 
cystic tumor  in  the,  427  ;  hydatid,  427  ;  me- 
dullary cancer  of,  565,  576,  586  ;  osteoid 
cancer  of,  646  ;  tubercle  in  the,  714. 

Thickening,  by  inflammation,  250:  of  skull 
74. 

Thrombus,  200. 

Thyroid  gland,  intra-cystic  and  detached 
growths  of,  341.  342  ;  tumors,  494;  cysts  in 
or  near  the,  361. 

Tibia,  lengthening  of,  77 ;  cartilaginous  tumor 
on  the,  448;  myeloid  tumor  in  the,  463 ; 
great  osseous  tumor  of  the,  476.  • 

Time,  an  element  in  disease,  328  ;  in  adjust- 
ment of  organic  processes,  33. 

Tissues,  influence  of,  in  inflammation,  239. 

Toe,  osseous  tumors  on  the  great,  479. 

Tongue,  epithelial  cancer  on  the,  606  ;  fatty 
tumors  in  or  near  the,  400  ;  fibro-cellular  tu- 
mor in  the,  414. 

Transformation,  in  disease,  327  ;  of  diseases  in 
hereditary  transmission,  676;  of  natural 
structures  into  cancerous,  688. 

Transition  tumors,  509. 

Transplanted  parts,  fatty  degeneration  of,  260. 

Traumatic  gangrene,  317. 

Travers,  Mr.,  on  healing  in  the  frog's  web,  153, 
154  ;   on  inflammation,  208. 

Trembley,  experiments  on  hydrse,  124. 

Treviranus,  on  the  excretion-office  of  each  part, 
38. 

Trigeminal  nerve,  influence  on  nutrition,  53. 

Tuberculous  disease,  incompatible  with  can- 
cer, 674,  551. 

Tubercle,  707  ;  type  in  the  lungs,  707  ;  gray 
and  yellow  forms,  707-8;  minute  structure, 
708  ;  origin  in  epithelial  cells,  709  ;  origin 
of,  in  connective-tissue  corpuscles,  710  ; 
abortiveness,  711 ;  degeneration,  711  ;  soft- 
ening, 711;  discharge  by  ulceration,  712 ; 
cavities  and  ulcers,  712;  tuberculoid  sub- 
stances, 713;  scrofula,  714.  In  lymphatic 
glands,  716  ;  in  integuments,  718;  in  bones, 
719.  Likeness  to  inflammation  and  to  can- 
cer, 721. 

,  cancerous,  on  the  face,  621. 

Tumors :  see  the  specific  names — e.  g.  Serous 
cyst,  Fr/tty  tumor,  &c.  ;  contrasted  with 
hypertrophies,  338 ;  with  products  of  in- 
flammation, 338  ;  their  property  of  growing, 
339  ;  nutrition,  irrespective  of  the  rest  of 
the  body,  341;  as  parts  overgrowing,  341; 
cessation  of  growth,  341  ;  Maligjiant,  gene- 
ral characters  of,  343,  e.  s. ;  innocent  con- 
trasted with  malignant,  347  ;  recurrent,  dis- 
tinctive characters  of,  347,  509 ;  proportions 
assigned  to  injury,  348  ;  supposed  origins  of, 
348  ;  classification  of,  343,  349,  &c. ;  divi- 
sion and  nomenclature,  349  ;  classification  of, 
objections  to,  351 ;  distinguished  from  inflam- 
matory products,  298. 


INDEX. 


737 


Tunica  vagiaalis,  containing  seminal  fluid,  372. 
Turck,  Dr.,  on  atrophy  of  the  columns  of  the 
spinal  cord,  117. 


U. 

Ulcer,  cancerous,  547,  608 ;  cancroid,  620 ; 
perforating,  311  ;  of  stomach,  622;  rodent, 
621 ;  specific,  324,  &c.  ;  becoming  seats  of 
cancer,  311. 

Ulceration,  288 :  and  see  Inflammation ;  in 
sloughing,  319  ;  liability  of  certain  tumors 
to,  344  ;  of  cancer,  547  :  and  see  Cancer, 
general  pathology;  contrast  of  cancerous 
with  simple,  345  ;  tuberculous,  718. 

Ulna,  increased  after  injury  of  radius,  78. 

Union,  immediate,  or  by  the  first  intention, 
1.34;  by  adhesion,  146  ;  of  granulations,  165. 

Urethra,  vascular  growths  in  the,  505. 

Urinary  bladder,  hypertrophy  of,  70,  72;  po- 
lypus in  the,  404  ;  villous  cancer  in,  654. 

Uterine  growth  and  tumor,  contrasted,  338. 

Uterus,  development  in  pregnancy,  66  ;  fatty 
degeneration  after  parturition,  107  ;  growth 
of,  around  tumors,  338  ;  tumors  imitating 
the  structure  of,  338  ;  epithelial,  cauliflower- 
cancer  of,  619  ;  fleshy  tubercle  of,  422  ;  fib- 
rous tumors  in,  425,  429  ;  fibrous  polypi  of, 
422  ;  cysts  in  fibrous  tumors  in  the,  427. 


Vaccination,  effects  of,  303. 

Vaccine  virus,  effects  on  blood,  57. 

Vagina,  fibro-cellular  tumors  by  the,  411  ;  epi- 
thelial cancer  of,  619. 

Vascular  and  non-vascular  parts,  47. 

tumors  :  synonyms,  495  ;    likeness  to 

erectile  tissue,  496  ;  chief  kinds,  497  ;  capil- 
lary, 497  ;  arterial,  500  ;  venous,  502  ;  gene- 
ral characters,  504  ;  enlarging  blood  spaces, 
504  ;  tissues  affected,  505  ;  general  charac- 
ters of  subcutaneous  nsevi,  505;  cysts  in,  507, 
361";  relation  to  cancers,  508. 

Veins,  healing  of  injured,  196  ;  dilated  into 
cysts,  369  ;  cancer  in,  673,  700. 

Venom  of  insects,  &c.,  331. 

Venous  vascular  tumors,  502. 

Vertebrffi,  cartilaginous  tumors  on  the,  444, 
451;  tuberculous  disease  in,  719. 


Villous  cancer  :  general  characters,  653  ;  den- 
dritic growth,  655  ;  bloodvessels,  666 ;  struc- 
ture, 657. 

Virchow,  Prof.,  on  amyloid  degeneration,  89  ; 
on  cauliflower  excrescence,  619  ;  on  ecchon- 
drosis  prolifera,  474;  on  fatty  degeneration, 
91,  e.  s.  ;  on  inflammation  of  muscles,  285  ;  of 
the  cornea,  286  ;  on  malum  senile,  108  ;  on 
neuralgia,  118  ;  on  obstruction  of  cerebral  ar- 
teries, 116;  on  origin  of  pus,  266,  cancer, 
689,  and  tubercle,  710,  from  pre-existing  tex- 
tural  elements,  notes  ;  on  rarefaction  of 
bones,  538;  on  tubercle,  709,  710,  714;  on 
vessels  in  erectile  tumors,  503. 

Virus,  eff'ects  of,  302. 


W. 

Waller,  Dr.,  on  formation  of  new  nerve-fibres, 
204  ;  on  effects  of  division  of  nerves,  117. 

Walshe,  Dr.,  on  cancer,  520,  561,  678,  680,  Ac: 
on  rarefaction  of  bones,  538. 

Wardrop,    Mr.,  case   of  healing  by  scabbing, 
166  ;  on  medullary  cancer,  577,  645,  &c. 

Warren,  Dr.,  on  lepoides,  628  ;   on  colloid  can- 
cer, 662. 

Warts,  becoming  seats  of  cancer,  628. 

Warty  growths,  601,  620  ;  on  scars,  623. 

cancer  :  see  Epithelial  Cancer. 

Wasting  palsy,  98. 

Wearing  out  of  parts,  27. 

Williams,  Dr.  C.  J.  B.,  on  varieties  of  lymph, 
235,  note. 

Dr.  Robert,  on  morbid  poisons,  329,  e.  s. 

Wood,  Mr.  Wm.,  on  painful  subcutaneous  tu- 
bercle, 416. 

Wormian  bones,  in  hydrocephalic  skulls,  73. 

Wounds,  repair  of,  132,  e.  s.  :  see  Repair. 

Wright,  Dr.  S.,  experiments  on  Aetinia,  126. 

Wrist,  osseous  tumor  on  the,  472. 


X. 


Xanthose,463. 


Zoology,  comparison  of  nosology  with.  J05. 
I  Zwicky,  Dr.,  on  organization  of  blood,  134,  lyy. 


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